By Otive Igbuzor
The World Health Organisation (WHO) is the directing and co-ordinating authority on international health within the United Nations System.[i] WHO experts produce health guidelines and standards and help countries to address public health issues. WHO also supports and promotes health research and has a membership of 193 countries and two associates. On 30th January 2020, the WHO declared the 2019 Corona virus disease (COVID-19) outbreak a public health emergency of international concern (PHEIC). Since then, WHO has issued guidelines to support countries to respond to the pandemic. WHO guidelines have been organised around six strategic objectives to:
- Interrupt human-to-human transmission including reducing secondary infections among close contacts and health care workers, preventing transmission amplification events, and preventing further international spread. This can be achieved through a combination of public health measures, such as rapid identification, diagnosis and management of the cases, identification and follow up of the contacts, infection prevention and control in health care settings, implementation of health measures for travellers, awareness-raising in the population and risk communication,
- Identify, isolate and care for patients early, including providing optimized care for infected patients,
- Identify and reduce transmission from the animal source,
- Address crucial unknowns regarding clinical severity, extent of transmission and infection, treatment options, and accelerate the development of diagnostics, therapeutics and vaccines,
- Communicate critical risk and event information to all communities and counter misinformation, and
- Minimize social and economic impact through multisectoral partnerships.
The World Health Organisation (WHO) has provided technical guidance on clinical preparedness, readiness and response to COVID-19. The idea is really that each country should assess its own risk and rapidly implement the necessary measures at the appropriate scale to reduce both COVID-19 transmission and economic, public and social impacts.[ii] The pathway of the disease can be divided into five phases:
i. No cases
ii. Sporadic cases
iii. Cluster of cases
iv. Community transmission
v. Country wide transmission.
The priorities should be different depending on the phase. When there are no cases, the focus should be on preparation including set up of COVID-19 designated hospitals. When there are sporadic cases, the focus should be on screening, care of suspected and confirmed patients, contact tracing and quarantine of contacts. When there are cluster of cases, the priority should be to scale up screening, improve care of suspected and confirmed patients, increase number of designated hospitals (including intensive care units, ICUs) and establishment of new structures to augment the health system. When it is at the community transmission and country wide transmission levels, it is time to ramp up all interventions and establish new hospitals and temporary structures, improving the referral system and introducing new cohorted community facilities and treatment at home. It must be noted that irrespective of the stage, it is necessary to have the right messaging for the public and ensuring health facility readiness, health staff readiness, referral system readiness and maintaining essential health services because COVID-19 has not suspended other diseases. It has been suggested that Nigeria is moving from stage 3 to stage 4 necessitating the need to ramp up all interventions.
The World Health Organisation (WHO) has issued guidelines dealing with several areas including national co-ordination, monitoring and evaluation, strategic communication, public health and testing. WHO recommends that countries activate co-ordination mechanisms as early as possible and well before community transmission occurs. The co-ordination mechanism should involve a whole-of-government and society approach that will include key sectors such as health, transport, travel, trade, finance, security and other sectors. It also recommends a monitoring and evaluation system to assess the effectiveness of measures and document lessons learned to inform ongoing and future activities. Strategic communication is required to communicate to the public what is known, what is unknown and what is being done to address the pandemic. In addition, WHO has provided three key public health objectives at all stages of the preparedness and response to COVID-19 namely to prevent outbreaks, delay spread, slow and stop transmission; provide optimised care for all patients especially the seriously ill and minimise the impact of the pandemic on health systems, social services and economic activity. Finally, WHO has provided a laboratory testing strategy recommendation for COVID-19.[iii] The aim of the strategy is partly to enable countries to increase their level of preparedness, alert, and response to identify, manage and care for new cases of COVID-19, laboratory testing being an integral part of the strategy. It gives guidelines on good laboratory practices and guidance to policy makers depending on the stage of the disease in the country.
Meanwhile, the first case of COVID-19 was confirmed in Nigeria on 27th February 2020 when an Italian citizen in Lagos tested positive for the virus. On 9th March 2020, the second case was reported in Ewekoro, Osun State from a Nigerian citizen who had contact with the index case. On 17th March 2020, the third case was confirmed in Lagos from a returnee from the United Kingdom. On 18th March 2020, Nigeria confirmed five new cases and since then, there has been new cases almost on a daily basis. As at 8th April, 2020, there were 276 confirmed cases, with six deaths and 44 recovered cases.
On 28th January 2020, the Federal Government of Nigeria assured Nigerians of its readiness to respond to the Covid-19 disesae in Nigeria. On 31st January, 2020, the government set up the Coronavirus Preparedness Group to mitigate the impact of the virus if it eventually spreads to Nigeria. On 17th March, 2020, Nigeria postponed the national sports festival. On 18th March, the NYSC suspended ongoing orientation camp. On same day Nigeria placed a travel ban on 13 countries. Two more countries were added on 20th March 2020. Several State Governments including Rivers, Ekiti, Kaduna announced lock down. On 30th March, 2020, the Federal Government announced a lock down in FCT and two states (Lagos and Ogun).
A review of Nigeria response will indicate that there has been appropriate policy response based on the WHO guidelines. When there were no cases, the government prepared for response including designated COVID-19 hospitals both at the federal and state levels. Mechanism was put in place for screening, care of the infected, contract tracing and subsequently lock down of two states(Lagos and Ogun) and FCT by the Federal Government and over ten states by state governments including Delta, Ekiti, Rivers and Kaduna States. The challenge has been the adequacy of the plans, capacity of the designated hospitals, number of tests that can be conducted daily especially given the large population of the country. Concretely, the challenges that have faced the response in Nigeria include leadership and co-ordination, capacity of the health system, testing, management of lock down, enforcement of social distancing, provision of palliatives, support by citizens and strategic communication. We have argued earlier that leadership is critical to the response to help minimise impact, save lives, protect property and infrastructure and restore public trust in government. There is a huge challenge of co-ordination between federal government, state government, private sector, NGO and citizens in the response in Nigeria. There is huge capacity gap of the health system to cope including availability of motivated workforce, testing kits and other equipment. The capacity of the health system to respond to the pandemic is low. Over the years, with a combination of poor funding, brain drain and poor stewardship, the capacity of the health sector is low. The capacity for daily testing of 50 persons is very low compared to other countries. The management of the lock down has also been a big challenge. Those exempted from the exercise have challenges getting transport of navigating through security check points. The conduct of some security officers in enforcing the lockdown is counterproductive. In lagos, some of them destroyed good of citizens and in Delta one person was killed. Enforcement of social distancing is still a challenge. Many people appear not to see the magnitude of the challenge in addition to the fact that changing habit is very difficult. One of the biggest challenges is the provision of palliatives. The response of the Federal Government is to continue with provision of cash transfer to the poorest of the poor which it has been doing. This posed a lot of challenges because the project covers just above eleven million people and there are over 100 million Nigerians living below poverty line. Indeed, this will probably be the greatest challenge and government and other stakeholders need to ramp up response in this regard. This is the only way to get support of citizens which is critical for the response. These challenges outlined above are being exacerbated by poor strategic communication, poor health system and transparency and accountability issues.
The next two weeks will be crucial for the response in Nigeria. First and foremost, there will be the need to extend the lock down because the most effective strategy is to focus on prevention and control especially as we have poor health system and inadequate capacity for testing. Secondly, there is the need to improve co-ordination among all arms and tiers of government as well as other stakeholders. There is the need for a robust mechanism to get volunteers in all areas of the response even beyond medical personnel. Capacity for testing need to be ramped up quickly as government procures more testing materials. The security agencies should develop and publish protocols for policing the lockdown. The army should not be involved in policing the lockdown for they are not trained for such duties. The provision of palliatives should be increased and well managed in a transparent manner. There must be a verifiable list of all beneficiaries. Finally, strategic communication needs to be ramped up. This is where volunteers may be useful. There is the need to involve religious leaders and civil society organisations in community communication and mobilisation. Finally, transparency and accountability in the response will increase citizens support for the process. This is the time to implement President Muhammadu Buhari directive that expenditure should be published online regularly. The COVID-19 response team at all levels should be giving regular financial update of their expenditure showing the cost of purchases. This will help monitoring as prices of items can be verified.
The COVID-19 disease is a rampaging pandemic across the world. The WHO has issued many guidelines to manage the pandemic. Nigeria is doing fairly well in managing the pandemic using the WHO guidelines but there are many challenges exacerbated by the governance challenges in the country. The country is at a critical stage at the moment. If we look at the exponential growth experienced in the other countries, the outlook becomes scary for Nigeria and the next two weeks will be critical in the response. Countries like Italy, Spain, US and UK moved quickly from a few cases to thousands of cases within a period of one month. For instance, while there were only 21 cases in Italy on 21 February 2020, by 27th March 2020, it has increased to 86,498. In France, it increased from 18 cases on 26th February 2020 to 32,964 on 27th March 2020. In United States, it increased from 16 cases on 21st February 2020 to 100,037 on 27th March 2020. In Germany, it increased from 18 cases on 25th February 2020 to 50,178 on 27th March 2020. In Spain, it increased from 25 cases on 25th February 2020 to 64,059 on 27th March 2020. The only way to prevent this kind of scenario in Nigeria is to strengthen the prevention and control measures in the coming weeks and manage the challenges that flow from it especially in terms of leadership, co-ordination, palliatives and accountability.