…the COVID-19 pandemic… Nigeria is comparatively at an early stage and we can learn lessons from the experiences of countries that have been battling with the virus. The government, in conjunction with the people, should act promptly, thinking globally but acting locally, and begin to implement measures that have been shown to be help in the control of spread of the disease.


Introduction

Nigeria is still at a relatively early stage of the COVID-19 pandemic caused by a newly discovered coronavirus called the SARS-Cov-2 and therefore has the advantage to learn from other countries that have been ravaged by the disease and should spend this time to prepare carefully in containing the disease, suppressing transmission and getting ready to scale up hospital capacity. To do this effectively, the leaders of the country need to think globally but act locally in their actions with respect to this highly contagious disease. Also, healthcare workers and the general populace need to realise that they have a significant role to play in this and hence work with the government to achieve the above goals. Whilst this is a new disease with a lot to still unravel about it, what we know now informs the need to take it very seriously – it is a highly infectious disease, there are no known preventive measures, no proven treatment/cure, no available vaccine and infected people not showing symptoms can transmit the virus.

Testing For COVID-19

The diagnosis of COVID-19 needs confirmation by a complex test in the laboratory, which looks for the presence of genetic material from the virus in samples from the patients. This testing is crucial to understand the presence and spread of the disease in society. Nigeria needs to decentralise testing in order to improve the turnaround of results and hence to start tracing contacts who had recently been in touch with the infected persons quickly. A centralised testing system, which the country is using at the moment, is bedevilled with several challenges, including logistics, the batching of samples at the collection points and batching at the central testing centres; all of these will result in longer turnaround time of the results. At present, it takes three to five days to report cases, especially for those coming from outside the testing centres. A timely turnaround of result is ideally within 24 hours but certainly under 48 hours. The prolonged centralisation of testing was a mistake made by many European and North American countries at the beginning of their own epidemics and many have struggled to suppress the transmission because of that. Whereas countries such as South Korea, Singapore and Germany that tested widely were able to suppress transmission and they have recorded the least numbers of deaths. Nigeria is definitely in a position to do this as every state in the country has a molecular laboratory (used for HIV diagnosis) that can be used for the diagnosis of COVID-19. I will also suggest that the Nigeria Centre for Disease Control (NCDC) should look into diversifying the platforms used as that will allow them to get reagents from different suppliers, rather than struggling with a single supplier.

There is also the need to look for an easier way of collecting samples. The current collection method of sticking a swab stick to the back of the throat and nostrils is not easy and can lead to false negative results, if not properly done. However, recently, saliva from infected persons has been reported to be as effective as swabbing the nose/throat and this is far much easier to collect. Nigeria can work on such a method and pilot the use of saliva, alongside nasal/throat swabs at this early stage. Moreover, the country should seek to learn from other African countries, such as Senegal, which have developed their own quicker diagnostic techniques, using saliva and blood samples, which are easier to collect and transport.

Testing For Other Diseases

The common symptoms of COVID-19 are fever, cough and body aches, with shortness of breath in the more serious cases. The common diseases in Nigeria that can mimic COVID-19 are malaria, with the fever and body aches; and tuberculosis (TB), with the cough. These two diseases are much easier to diagnose now. So, acting locally, it should be mandated that every new case of fever presenting to any healthcare facility should have a blood test for malaria, as well as the swab for COVID-19. A positive malaria test should be treated and patient observed. A negative malaria test should immediately trigger contact tracing and isolation of the patient. Also, new patients should be given a new face mask to wear on arrival at a healthcare facility. Equally, all healthcare practices should heighten their index of suspicion and approach any new patient with as much caution as possible, including at least wearing a face mask and eye protection.

…achieving a near successful lockdown and social distancing will be a challenge in a society like Nigeria with a strong communal living system and reliance on daily market activities for sustenance, especially given the poor infrastructure for storage. Hence for this to be effective at all, there is need for original thinking and strong collaborative working with the community directly.


Lockdown and Social Distancing

The lockdown of the society enables social distancing and this is crucial to slowing down the community transmission of the disease. However, achieving a near successful lockdown and social distancing will be a challenge in a society like Nigeria with a strong communal living system and reliance on daily market activities for sustenance, especially given the poor infrastructure for storage. Hence for this to be effective at all, there is need for original thinking and strong collaborative working with the community directly. Such existing community groups as religious organisations, of churches and mosques, as well as civil liberty groups should be engaged in this. The religious networks of churches and mosques should be used as people are more likely to listen to their pastors and imams more than government officials. These religious leaders and their organisations should be engaged in the public health awareness about this disease.

Lockdowns and social distancing affect people’s livelihoods, so to be effective, relief measures must be put in place. Innovative ways need to be sought to achieve this. For example, all available local halls – church, school, event centres and town halls – could be used to distribute relief materials in a controlled way. Some of these facilities should be turned into emergency shopping outlets, with the ability to control crowds and maintain the distancing of marketers and customers. Larger spaces, such as school (including higher institutions) playgrounds, stadiums and army barracks could be turned into temporary markets, where people can be counted in and monitored. In addition, relief materials can be directly delivered to people, especially in smaller community groups.

The military and civil society groups should be actively engaged in logistics, distribution and security, with respect to relief materials in particular. The leaders need to publicly demonstrate more social distancing actions than just wearing face masks. Whilst the wearing of face masks may play a role in curtailing the spread of the disease from infected persons to those around them, this needs to be accompanied with more important social distancing actions such as desisting from handshakes and embraces, and regular handwashing, while keeping two-metre distances from others.

The value of effective lockdown and contact-tracing can even be seen in Nigeria now, with some states such as Ondo keeping the spread down from their index case for several weeks, whereas in Kano which had an ineffective lockdown, the confirmed cases have increased astronomically within two weeks. Also, as it appears, the disease is largely urban based at the moment, part of the strategy should be to strongly discourage city dwellers from visiting their villages and vice-versa, as it will be difficult to monitor the situation in those largely out of reach villages.The more vulnerable members of the society (the elderly and those with underlying diseases like obesity, diabetes, hypertension and lung diseases like asthma, in whom the diseases may have serious consequences) should be strongly encouraged to shield themselves from others to minimise their risk.

Plans should also be made for surges in bed occupancy for non-ICU cases, including preparing and designating some hospitals as COVID Hot and maximising their capacities. Some of the re-possessed public spaces can also be converted to emergency hospitals for milder cases, while health care workers are trained to manage them.


Prepare for Surge in Hospital Capacity

The main cause of death in the disease is when people developed serious breathing disorder, which requires hospital admission and treatment often in intensive care units (ICUs), where machines are used to assist the breathing and delivery of oxygen to the patient’s lungs. A widespread transmission of the disease increases the chances of this happening and the resultant overwhelming of the critical care capacity of hospitals. This contributed significantly to the high death rates from the disease in the Western countries, especially when they did not prepare well for the surge. Therefore, a thorough assessment of the ICU capacity in government and private hospitals is required and then plans to increase the capacity by using operating rooms. Plans should also be made for surges in bed occupancy for non-ICU cases, including preparing and designating some hospitals as COVID Hot and maximising their capacities. Some of the re-possessed public spaces can also be converted to emergency hospitals for milder cases, while health care workers are trained to manage them. More medics and nurses should be trained in intensive care work and refresher courses run for medical workers who have had less clinical work to increase their capacities. It is important to work collaboratively with private healthcare providers, as they represent more than 60 per cent of care facilities in the country and largely act as the de-facto primary health care system.

Wider Engagement With Industry

There is a need to work with industry and universities to produce materials locally, especially personal protective equipment (PPE) including producing face masks with local materials in order to make the specialised ones available for use in healthcare facilities by patients and healthcare workers. Government should also encourage and facilitate the local production of some of the chemicals for testing, ventilators and mobile phone apps for contact-tracing and distribution of materials. People should, in addition, be empowered to produce practical handwashing systems that allow for the free flowing of water by, for example, adding taps to the end of buckets on a stand to facilitate handwashing and improved levels of hygiene.

Conclusion

In summary, the COVID-19 pandemic is real and spreading fast. As at the time of this writing, more than 3.2 million cases have been documented worldwide, with 210 countries affected. Sadly, more than 200,000 people have died and the number is steadily rising. Nigeria is comparatively at an early stage and we can learn lessons from the experiences of countries that have been battling with the virus. The government, in conjunction with the people, should act promptly, thinking globally but acting locally, and begin to implement measures that have been shown to be help in the control of spread of the disease.

Olorunda Rotimi is a consultant Histopathologist and a clinical director for pathology in a large teaching hospital in the United Kingdom, which oversees a laboratory involved in the diagnosis of COVID-19. This article is written in a personal professional capacity.