COVID-19 control in poor countries: what can be done?

COVID-19 control in poor countries: what can be done?

“The world is four months into the COVID-1 9 pandemic, and it is now clear that we are facing an acute public health, economic, and humanitarian crisis. What makes managing this health emergency so challenging is that if unattended, it could lead to countless numbers of fatalities—yet if drastic measures to contain the spread of the virus are imposed, it can produce a deep recession with business closures, mass unemployment, and poverty. As the Economist writes,“the trade-off between saving lives and saving livelihoods is excruciating.’’ World Bank -April 7, 2020.

In Africa and other poor countries, with shaky long unfunded health system covid 19 pandemic is a time bomb waiting to explode. As the case escalate it obvious that these poor equipped health facilities will get overwhelmed.

According London school of hygiene and tropical medicine, health in humanitarian crisis center covid 19 impact on people living in low income settings or affected by humanitarian crises could lead to substantial excess mortality due to: higher transmissibility, Higher infection-to-case ratios and progression to severe disease and Higher case-fatality

1. higher transmissibility due to:

Larger house hold, Intense social mixing, Overcrowding in urban slums and displaced people’s camps, Inadequate water and sanitation, Super-spreading event – mass praying, funeral, wedding and marketing, Inadequate testing, surveillance and isolation due to scarce public health human resources and limited financial resource.

But in most African urbanization is minimum, in Ethiopia more than 80% of population live in rural area. This may provide epidemiological buffer that is provided by social distancing and isolation in developed countries.

2. Higher infection-to-case ratios and progression to severe disease due to:

Higher rate of HIV infection and resurgence of tuberculosis epidemic due to HIV, Adult malnutrition, Prevalence of hypertension and diabetes is often higher in low- than high-income settings, with a far lower treatment coverage.
Despite the fact that sub Saharan Africa contains only about 11% of world population, the region is the world’s epicenter for HIV/AIDS. In Ethiopia current data shows the prevalence of HIV is rising at alarming rate. Tuberculosis epidemic is driven by HIV, and HIV-tuberculosis coinfection has clear impact on mortality. Though WHO and UNAIDS are compiling data and evidence, the immune status that makes people with HIV vulnerable to tuberculosis could also make them susceptible to coronavirus infection.

3. Higher case-fatality due to: Poor health infrastructure, few health care workers and progression to severe disease may be higher.

Higher case fatality may be counterbalanced by high younger age distribution but its real effect is yet not known in such setup.

4.Indirect effect

The magnitude of indirect health effects may be substantial and long lasting. The impact of covid 19 may stretches far beyond covid 19 deaths. Even with draconian suppression measures, COVID-19 may rapidly overwhelms these fragile healthcare systems. As more patients are hospitalized, healthcare workers at the frontline of delivering care are at the greatest risk of contagion. Worse, if infection prevention and control (IPC) systems are not in place and IPC practices are not widely followed, health facilities can drastically speed up the spread of the virus. As case escalate fear and mistrust of the health services, the closure of health facilities or changing it into covid center, and sickness or deaths of health care workers will result in decreased health provision and health uptake leading to increased morbidity and mortality from non covid 19 case.

Child and Maternal health services such delivery at health facility, antenatal and postnatal care, family planning and vaccination coverage will be decreased which will increase maternal and child mortality and morbidity

HIV/AIDS, tuberculosis and other service will significantly decrease.
Prevention program and treatment of malaria, cholera/diarrhea, measles and other disease may get disrupted.

What can be done:

1. Community based transmission control

It is essential that all measures are acceptable and well communicated to communities, and not perceived as an oppressive measure so that they can self-organize so rapidly and spontaneously along a set of epidemiologically sound principles.
People involved in social mobilization , including community and religious leaders , community activist, primary health care workers , and volunteers , will be selected to be trained and they will be asked to promise to distribute the message of COVID 19 prevention to their community members via face-to-face communicating , or distribute posters and brochures.

Health care workers will survey and help the community in providing culturally appropriate health information on behavior change and facilitate their decision

Government and other institutions could contribute by supplying infection control supplies (e.g. soap and water), supporting livelihoods, enabling local care committees and providing or strengthening mobile, dedicated medical treatment.

2. Protecting vulnerable group.

Vulnerable groups such elderly, those with ill health and comorbidities, refugee, homeless or underhoused people need special protection strategies.
Basic public health measures, such as social distancing, proper hand hygiene, and self-isolation are not possible or extremely difficult to implement in refugee camp, homeless or underhoused people.

Protection of these group can be at household level, neighborhood level and community level using different mechanism.
Interaction with these group should be restricted and through limited zone at which sanitization made.

When wide spread community transmission occur it is impossible for the government to isolate all case in governmental institution. At this level community can create green and red zone where suspected case get isolated.

Refugee camp visitors should be limited.

3. Limiting superspreading event.

Mass gathering such Large meeting, school, sport event, religious event, marketing place, weeding, funeral and other event should be limited if possible, prevented.
Marketing place should be rearranged for possible social distancing and local community can arrange limited number of their representatives who will go to market and buy needed material for all households.

4. Consistent, regular and effective communication

Messages and actions of response could lead to a higher level of trust through:
Acknowledging uncertainty in messages, including forecasts and warnings;
Being transparent and not concealing negative information, such as rates of casualties;
Speedily disseminating information and intervening;
Creating scientific communication in an easy to understand manner;
Seeking input from the public and encouraging a dialogue;
Ensuring coordination between different health authorities and the media along with a uniform message;
Avoiding rapid changes in information and preventing the dissemination of conflicting information from different agencies; and disseminating information through multiple platforms.

Area that need to addressed include

Daily regular update in multiple language.
What do people know and believe about the disease, its cause, and its
prevention/treatment/cure?
How does the community see illness and death – what is their health belief model?
What actions are they engaged in that increase their risk of exposure to the disease?
How do people in the affected areas take care of the sick? Whose help do they seek when they are sick? Traditional healer/community worker/hospital?
How does the community view how care is provided in hospitals and health facilities? Are hospitals or other health facilities trusted?
How are burials and funerals conducted

5. Fair allocation of scarce medical resources

Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus.Treat people equally but first-come first-served should not be used, but random selection used for selecting among patients with similar prognosis
Critical Covid-19 interventions – testing, PPE, ICU beds, ventilators, therapeutics, and vaccines – should go first to front-line health care workers and others who care for ill patients who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response.
Priority for critical workers must not be abused by prioritizing wealthy or famous persons or the politically powerful above first responders and medical staff

Available scarce money resource should also go for material which can save most lives … expanding ICU bed and availing adequate mechanical ventilator may be difficult but simple material which could save most live such as oxygen, bed, tents and other should get ready.
Poor countries could not afford lose of health care worker. According to WHO and UNICEF report during Ebola outbreak in western Africa by May 2015, 1.45% of Guinea’s doctors, nurses, and midwives had died of Ebola; in Liberia, 8.07% died and 6.85% died in Sierra Leone which have a lasting impact on population health, estimate that approximately
25,000 additional deaths per year could occur due to the death of health-care workers. When HCW death is due inadequate PPE provision it will create fear and stress among others. So, government should be very serious about provision of PPE.

6. Universal homemade face mask

Unwitting transmission is very high than previous thought and aerosol transmission is also possible. Though home made facemask may not prevent aerosol transmission it will significantly decrease transmission from infected person to others through droplet. It is also less expensive to use.
Use expensive face mask such us N95 should be limited to persons or HCW caring for confirmed Covid patients.
But face mask cannot substitute other infection prevention method, so it should not provide sense of security from infection.

7. Testing, isolation and quarantine
8. Continuation of other health provision
9. Effective leadership
10. Hot spot partial lockdown

I will continue with last 4 points…..

Jemal Markos