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The failure to contain the pandemic means that efforts must be redoubled, not ruled out
me Please read Dr. Daniel Hailu’s Ethiopia Insight article of July 21 with great interest.
His first-hand experience with the diagnosis and isolation of COVID-19 at one of the treatment centers in Ethiopia has given us unique insight into how the system is working. I really appreciate your effort and willingness to take the time to give us this perspective.
The Ministry of Health (MINSA) and others responsible for the operation of the center must take their comments and recommendations seriously and try to correct the living conditions and the logistical deficiencies in those places. In addition to the living conditions, Daniel has made a series of criticisms and recommendations on the public health strategy that Ethiopia is following to combat the COVID-19 pandemics.
Appreciating your astute observation and measured recommendations, I wanted to respond to some of the criticisms and recommendations you raised in your writing.
Public health in general and prevention activities in particular are often victims of its success. What it prevents and avoids is generally not news and is difficult to quantify. This is the reason for the apathy in financing prevention strategies. We introduced a measles vaccine and what has been a deadly disease is now practically eradicated.
Unfortunately, there are many who have the luxury of not knowing the disease thanks to the effective vaccination campaign, leading the anti-vaccine movements. The same can be said for an effective preventive strategy for COVID-19. What it prevents is difficult to measure and is therefore open to criticism.
The irrelevance of containment in response to Ethiopia’s COVID-19
By Daniel Hailu
COVID-19 is a highly communicable disease, and therefore any country whose strategy is solely to prevent community transmission will eventually fail. Ethiopia, like any developing country with limited capacity, has come to terms with this fact and was working hard to mitigate the impact of a community transmission when it arrives.
All the measures that have been taken since then, including the closure of flights, the quarantine of arriving travelers, the tracing and isolation of contacts, the face mask and testing, have had an impact on community transmission and therefore thus, in the trajectory of the pandemic. How much is difficult to calculate, but based on previous model estimates, it must be a lot.
Of course, things could have been better, and sometimes they should have been. We were slow to improve contact tracing, increasing public use of cloth masks, and increasing testing. Those interventions would have slowed the trajectory even further and reduced the actual number of cases that we are seeing now.
But thinking that the containment strategy implemented by the country has now failed and of little impact cannot go beyond the truth. If I have a criticism to make, it is for failing to improve public health strategies rapidly and at an unprecedented rate to match the dangers of pandemics. This has not been done on the scale required by the pandemic and remains a criticism to be made.
Let’s see the facets of this program one by one:
Widespread community transmission
I agree with the document that there is now widespread community broadcasting, particularly in Addis Ababa. With this in mind, it is easy to assume that there are several asymptomatic cases in the community that transmit and fuel pandemics in Addis Ababa.
Unfortunately, the agreement we have ends here.
The best proven intervention that a country can introduce when there is widespread community transmission is to increase testing, trace contacts, and isolate contacts. The transmission of COVID-19 is such that, on average, one infected person has the potential to infect three others during their illness. The only way to eliminate this is to isolate the patient early and interrupt potential transmission. The current doubling time in Addis Ababa is around 12 days. This means that each infected case has a six percent chance of infecting a person on a daily basis. As the incubation period is 14 days, each day adds a potential transmission risk of 6 percent. Effective contact tracing will dramatically reduce this by shortening the time a case spends in the community from 14 days to the shortest possible time (depending on how quickly the contacts are traced and isolated).
Therefore, even in times of high transmission, peak of the pandemic, contact tracing and isolation will continue to play a critical role, although in the fog of such a high number of cases, it is often difficult to notice the impact of this. critical intervention. As Daniel has clearly identified, our contact tracing could have been much more rigorous and organized. Our estimated recommendation was at least 1,600 contact markers in Addis Ababa and around 40,000 in the country. To date, we are very far from our goal and this has clearly been the Achilles hill of our prevention, making this fundamental pillar of the COVID strategy one of the weakest links.
Low per capita test
Ethiopia has tested just over 400,000 people since the first case was detected in mid-March 2020. Its daily capacity is still around 6,000 tests (there is a significant improvement in testing since the start of the COMBAT campaign). For a country of more than 100 million people, this is one of the lowest daily tests per capita. That said, there is another way to look at this low testability. So far, more than 70 percent of all cases are in Addis Ababa, and testing is also mainly done in Addis. Considering that, for a population of five million residents in Addis, the testability is not as desperate as it seems when looking at per capita from the perspective of the entire country.
As in many countries, the pandemic in Ethiopia unfolds city by city and region by region. At this time, there is sustained community transmission in Addis. There is little evidence to suggest that this is the case in the regions. If that’s true, without sustained community broadcasting, expanding testing just to increase testing is not a smart strategy.
The performance of each test is another way of looking at the justification of the test. As Daniel has clearly stated, testing is critical to tracking and isolating contacts. It maintains that with the current low rate of testing, without first increasing testing capacity, tracing and isolating contacts is not a rational approach. I look at this from a different angle. Countries that have effectively controlled COVID-19 have reported a minimum of 30 human contacts traced for each identified positive case. If we were to saturate that, then without increasing testing, scaling up contact tracing might not bring the expected benefit. Right now, Ethiopia is tracking about six people for every positive case identified. This leaves a lot of room for our system to improve. For this reason, until we achieve the minimum required contact tracked by tested number, even at low testing capacity, tracking and isolating contacts remains a fundamental pillar of our public health strategy.
Isolate infected people
- Management: Daniel has this point very well. I urge MINSA to examine the isolation centers and address the deficiencies identified by Dr. Daniel. Isolated COVID-19 patients are potential cases that could transmit disease, and unless proper isolation precautions are taken, we will expose healthcare workers and others who interact with patients.
- Testing and Reevaluations: Based on published literature, the guidance on when to stop isolation and discharge COVID-19 patients has been changing. The current recommendation from the Center for Disease Control has made this clear and simple. COVID-19 cases that have been isolated for 10 days and have been asymptomatic for more than 24 hours should be discharged without the need for a test to confirm elimination. This should be the pattern in the isolation centers of Ethiopia.
- Implementation of the case registration form: Daniel’s observation on this is both powerful and discouraging. We continue to rely on data from other countries because we do not carefully document our own observations and do not create locally relevant data. Our collection of data on paper in the age of the digitized world is one of the disappointments of our system. Your observation, recommendation, and criticism should be taken in a positive light and changes should be implemented immediately.
- Meeting Nutritional Needs and Preferences – Again, I applaud Daniel’s observation on this. Quick and substantial arrangements must be made to correct the delivery of proper nutrition. As the number of patients to be isolated increases by the day, this will continue to be a challenge for a country that has limited financial capacity. The cliché that more patients will die from non-COVID issues than COVID while in isolation could become a reality. With this in mind, for mildly symptomatic COVID-19 cases, transitioning to home isolation should be a priority to lessen the load on the system.
COVID-19 is a pandemic that people like our generation have not seen. It has devastated countries in its wake. The interventions that are tested and known to mitigate the pandemic, while simple and primitive at times, are immensely expensive. Quarantining and isolating thousands of suspicious people and patients and attending to their daily needs for 14 days is a huge task for any country. Ethiopia is no different in this regard. What needs to be criticized here is clear. Urgent attention must be paid to improving contact tracing, digitizing data collection, and improving conditions at quarantine and isolation sites.
The economic challenge and political unrest facing the country should not be a reason not to improve the system. Every effort should be made to flatten the curve and ultimately decrease the number of total infections. Taking into account the limited system of tertiary health care, the country has, the expansion of hospital care to address this pandemic, a cause as noble as it is, it cannot be a coherent and viable strategy. Economic recovery depends on a good public health strategy.
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