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“Corona” Unlike Ebola-a Call for Caution and Way Forward in Nigeria By Dr. Bukar Abba Zarami
The ongoing coronavirus disease (COVID-19) pandemic (worldwide spread of new disease) has affected the global community, beyond any issue in recent memories. According to John Hopkins’ situation reports on the disease, over 372,757 persons were infected, and 16,231 died globally due to the disease. The highest mortality rate of 9.5% was observed in Italy. Nigeria, so far, has 51 confirmed cases and one death. Despite this pending disaster that has crippled major economies such as the USA, China, Italy, the UK, and other developed nations, some religious leaders in Nigeria are misleading the gullible public with different conspiracy theories.
At the beginning of the pandemic, some of them opined that the almighty God is punishing the ill-treatment of certain religious groups in China, while others dispelled public awareness campaigns against social gatherings that we had similar public health concerns during the Ebola outbreak. Still, we successfully managed it without cases ever spreading to most states in Nigeria, so why discourage social gatherings? Some religious leaders want their followers to attend worship places en masse so that they could use such opportunities to sensitize them on the emerging disease.
In Nigeria, religious leaders are highly revered persons who can easily influence public opinion or response, having followers who agree with their point of view, irrespective of the topic. Not all religious leaders are guilty of misleading their followers on health issues, preachers like Professor Ibrahim Ahmad, Dr. Ali Pantami, the current Minister of Communications and Digital Economy, and the Nigerian Supreme Council for Islamic Affairs (NSCIA) have passed useful information on controlling the disease. The Christian Association of Nigeria (CAN) also urged its members to comply with the governments’ directives on COVID-19, which is laudable.
Another group culpable is the Nigerian youth believing that COVID-19 only affects the elderly; young and fit people like them will only have flu-like symptoms. These are people who rely entirely on their aged parents for upkeep, yet they party indiscriminately dancing to new coronavirus track in night clubs. Unknown to them, a significant proportion of our youths have existing medical comorbidities that may lead to worst COVID-19 outcomes. Cases of young people presenting with severe disease were seen in other countries.
We have different COVID-19 write-ups in the cyberspace, but most of them come in smaller bits of information, giving room for misinterpretations to those with no medical background. In the following sections, I will elaborate on COVID-19 using Nigeria's context by first assessing the history of some important pandemics to dispel unfounded conspiracy theories, highlight why coronavirus disease is unlike Ebola virus disease, the need to practice social distancing and self-isolation, assess the country’s capability of handling a major outbreak and recommendations to manage the pandemic in Nigeria.
Dating back to history, we had experienced pandemics that posed a threat to humanity. They primarily arose from an existing disease acquiring new threats through a change in genetic composition to infect the human population in a larger scale or new organisms from other animals infecting humans. Notable among them was the Bubonic plague (black death), which killed over 200 million people from 1347-1351 AD; 30-50% of the European population was wiped out. Others were the Spanish Flu (1918-1919), killing 40-50 million people or, more recently, the HIV/AIDs pandemic, unlike the others, was kind enough to allow infected persons to live long before killing over 36 million people.
The emergence of new diseases is inevitable so long as humans exist, and the question should be when will the next disease emerge and how are we prepared to tackle it. The rapidity in the spread of a new infection is enhanced by globalization. Never in the history of humanity did the global community interact as much as we do now.
According to WHO and other reputable health websites, coronavirus disease shortened to COVID-19 is an infectious disease caused by a newly-discovered virus called severe acute respiratory syndrome coronavirus 2, or Sars-Cov2. It is transmitted via droplets of saliva or discharge of infected person during coughing or sneezing. The virus gets into the lungs, which has tiny holes within its cells that allow it to enter and multiply in the cells, eventually destroying the lungs, which primarily provides oxygen to the whole body. COVID-19 symptoms include fever, dry cough, tiredness, shortness of breath, and other flu-like symptoms. The incubation period (the time of contact between an infected person and the development of symptoms) ranges from 2-14 days, with an average of 5 days. At present, COVID-19 has no vaccines nor cure; patients are managed based on presenting symptoms until they recover or die from complications.
Going by the natural history of the disease observed from other countries, about 80% of patients have a mild illness without requiring hospital admission. It is estimated that 16% will have a severe illness (difficulty in breathing, higher frequency of breathing above normal, lower levels of oxygen in the blood) and the remaining 4 % will be in a critical condition (respiratory failure, widespread infection in the human blood, failure of one or more organ such as the liver or kidneys to function). The critical cases require intensive care treatment with oxygen and a mechanical ventilator (a machine that mechanically supports breathing when a patient cannot breathe on their own).
Superficially, it appears the disease has a good prognosis since up to 80% of patients recover following a mild illness; however, people older than 60 years and those with underlying co-morbidity such as uncontrolled hypertension, diabetes, HIV/AIDs, asthma and cancer are at highest risk for severe disease and death.
COVID-19 is unlike Ebola virus disease in many ways:
· Ebola is transmitted via contact with the body fluids of an infected person. Peter Piot, the co-discoverer of Ebola, said he could comfortably sit together with a person having Ebola on a plane unless the person coughs or vomits. COVID-19 is transmitted via droplet infection, and close contact of less than one meter or 3 feet could potentially spread the disease.
· Ebola is transmitted by an infected person manifesting with symptoms such as fever and vomiting; unfortunately, COVID-19 could be transferred from one infected person without symptoms to another healthy person. Meaning, even with normal body temperature and perfectly-being well, a person with COVID-19 could transmit the infection to others before even falling sick or with just mild symptoms! Therefore, routine temperature monitoring of people could still miss out some cases.
An important epidemiological concept in the transmission of infectious disease is the Basic Reproductive Number (Ro), which is the number of cases one case generates on average over the course of its infection period in an otherwise uninfected population. COVID-19 Ro is estimated to be between 1.5 and 3.5. It means, on average, an infected person could transmit the infection from 2 to 4 otherwise healthy persons during its period of infectivity. The same applies to the new cases who could potentially infect the same number of healthy people. The value of Ro depends on the stage of the disease and control measures in place. A Ro greater than one is needed to maintain an epidemic. This explains why we are experiencing continuous disease transmission.
Infectious diseases are usually propagated until all susceptible cases are exhausted (infected or died out). In simpler terms, COVID-19 is akin to bush fire, where all trees will continue burning until no tree is left out. The bush fire could be stopped by creating partitions between the span of a forest; by doing so, the fire has no option but to die out. This is exactly how social distancing works during the COVID-19 pandemic. It also gives an opportunity for the so-called epidemic curve to flatten, allowing the health system to respond with minimal strain.
Does Nigeria have the capacity to tackle the COVID-19 outbreak? A best-case scenario is a situation where all the 51 confirmed cases are the only cases in the country. All their contacts (100%) have been identified, quarantined for 14 days, tested, and treated (if they have developed the infection) or discharged home in the absence of the disease. Also, there is no single case of COVID-19 community transmission. It requires more than a miracle for this to happen, as explained earlier, due to the dynamics of the disease.
Before jumping to the worst-case scenario, we need to analyze some indicators in the Nigerian health system. Nigeria has an estimated population of 200 million people, 5.4 million is elderly (greater than 65 years), a reported doctor to patient ratio of 1;2500, but in reality, it is around 1;5000 due to brain drain. This means a single doctor caters to a population of 5000 people against the World Health Organization (WHO) recommendation of one doctor to 1000 people. We also have low availability of oxygen equipment and mechanical ventilators in our hospitals. The average Nigerian State has less than 15 Intensive Care Unit (ICU) beds (ICU is a place where critically ill patients are managed). Approximately about 50% of ICU beds have mechanical ventilators. I doubt if the whole country has up to 500 mechanical ventilators, which are not currently sufficient to meet the nation’s pre-COVID-19 demand. In terms of laboratory capacity to test COVID-19, only two geographical zones (South-West and South-South) out of the six have functional laboratories to conduct the test. The whole North and the South-East don't have any!
To answer the question, let's make some assumptions and hypotheses. We will use very conservative estimates to understand the magnitude of what we could be facing. In New York's pandemic, they figured 40-80% of the population could be affected. For Nigeria, I can't bring myself to use that estimate because it's unimaginable going by the vast number of people that could be affected. We can hypothetically use 20% (half of New York’s estimate) just to appreciate the magnitude of a worst-case scenario and this number is around 40 million. Remember, 20% of infected persons could come with severe disease requiring hospital admission. This is about 8 million people going by our hypothesis. About 4% or 1.6 million people may need intensive care treatment in a worst-case scenario! It is better for the assumptions to be wrong and prepare well than to discover it is right at a later stage of the pandemic. God forbids, but what type of miracle will you need to handle this?
Nigeria lost a golden opportunity to focus on containing the disease by closing all its international borders early without waiting for a case to be identified. COVID-19 is unlike Ebola; the successes of Ebola do not warrant the country to test the capability of its very fragile health system. Some developed countries are suggesting the triage of patients, meaning to sacrifice the very elderly in worst-case-scenarios. A pragmatic approach could have been the immediate closure of our international borders, only to allow citizens to return home. A quarantine center, may be a hotel, should have been used to isolate returnees for 14 days. This could have been achieved through emergency intervention funds from the government and mobilization of available human resources to contain the disease.
Hope is still not lost; we can still salvage the situation though requiring more resources. The first thing we need to do is to avoid panicking. The memory of people drinking table salt solution during the Ebola outbreak is still fresh in our minds, but a reasonable panic is needed for Nigerian's to comply with governments' directives. Government at all levels, the traditional and religious leaders, Non-Governmental Organizations (NGOs), philanthropists and everyone in the country have major roles to play. Some of the measures are already in place.
At the national level, the Federal Government should first close all our international borders before the disease gets out of hand. The country should be locked down for 14 days to control the disease spread. Special intervention funds to control COVID-19 through the Presidential Task Force on COVID-19 to lead the national response should be provided. It is also time for the National Orientation Agency and Ministry of Information to lead COVID-19 sensitization through their existing structure. The Federal Government should also liaise with automotive industries for them to have the capacity to produce mechanical ventilators, just in case things get out of hand. This measure will go a long way to fill critical gaps in our health system even after the COVID-19 pandemic in Nigeria. Industrial oxygen-producing plants should be upgraded to supply medical oxygen. The same applies to fabric industries, that can produce facemask that is in shortage across the country.
The intervention funds should also be channeled to provide oxygen equipment (cylinders, medical oxygen, pulse-oximeters, nasal canular, etc.), Personal Protective Equipment (PPEs), disinfectants, rapid diagnostic test kits, and other hospital supplies. The poor and vulnerable population will require support from COVID-19 bailout during the proposed homestay. About 50% of the national minimum wage should be given to this category of the population. Without a bailout, more people could die due to poverty and other prevalent diseases.
Instead of calling retired doctors who are already vulnerable to severe COVID-19 to support the response, the final year medical and nursing students in the country should be mobilized to join the response. It is also a time for the National Youth Corp Members to answer the clarion call as volunteers. The military and para-military should enforce compliance with government directives on COVID-19.
At the state level, it is commendable to see states like Kaduna, Yobe, Borno, Katsina, Kano, Rivers and others taking pro-active measures. States should consider closing their borders, allowing only food, drugs, and essential services to minimize spread. Market places should also be closed, except for areas where they sell food products. Similar to the federal government, states should also support their vulnerable population with a special intervention fund. Movements across IDP camps should be highly regulated because a single case in IDP camps during this hot season is a recipe for disaster. Hand-washing practices and personal hygiene should be promoted in IDPs. Another important measure is for states to continue providing essential health services across health facilities; otherwise, more people will die from other medical conditions such as malaria, HIV/AIDs, tuberculosis, maternal and child health issues, etc.
The State Emergency Operations Response Center (EOC) should be activated for COVID-19. Funds should be available for the center to lead the COVID-19 response. Social gatherings during naming and wedding ceremonies should be discouraged; this is a time for people to get married without the need to spend money on dinners and parties. For effective control, the recommended number of people during social gatherings should be further reduced from less than 50 to less than 10 (since most of Nigeria's family are up to that number. Germany recommended not more than two persons). Though controversial, religious leaders should encourage people to pray from their homes. This is currently practiced in Saudi Arabiya, where the two holy mosques are. It is better to save the lives of your followers than wake up one day without any older person to pray. Similar interventions should be carried out in LGAs.
At the individual level, we should be our brother keepers in this trying period. Those who can afford should help their neighbors with foodstuffs. It is a time for us to support the very poor and vulnerable people in our neighborhoods, especially the Almajiris. There's no need for panic buying if you have enough food. Practice social distancing in your homes and the community by keeping a distance of at least 1meter or 3 feet or self-isolation in suspected cases. Wash your hands regularly with alcohol-based hand sanitizers where available or just soap and water; avoid handshaking, touching your eyes, mouth, or nose. Please, do not take chloroquine, azithromycin, or any drug to treat COVID-19 until proven and recommended by the WHO.
Last but not least, we need to keep praying in our homes. Nothing is beyond prayers, but we have to do it in such a way that it doesn't contravene recommended guidelines. By God's grace, a worst-case scenario of COVID-19 will not happen in our dear country.
Bukar Abba Zarami (MBBS, DTM&H, DLSHTM, MSC.TMIH)
A Public Health and Tropical Medicine Specialist in Nigeria.
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