By Dr. Bertha Serwa Ayi
A beast is on the loose. A disease named COVID-19. Wall Street has eyes on the beast and its potential to turn a bull market into a bear market. Like a beast with a fire-lit tail it is going from country to country lighting up fires that devour human lives. The smoke of symptoms of infected patients is the first clue about its presence. By the time firefighters get there to quench the fire, there are four or five other fires. It is off to the next country. Globally it has sickened more than 82,000 people, and taken more than 2,800 lives. China, the world’s most populous nation with 1.4 billion people and its Hubei province has been the epicenter. Maybe that is about to change.
Last weekend the outbreak took an epic turn that could turn it into a pandemic. Italy has had to face this reality in a rude awakening. In Northern Italy, 50,000 people are under quarantine, schools are closing as the outbreak seems to be spiraling uncontrollable out of hand like a tsunami with 220 infected and seven reported dead in one day and 322 confirmed cases and 11 elderly people dead the next day. It is also fast becoming an epicenter. On Friday February 20, Iran reported its first two cases and within 72 hours there were over 61 cases and 12 deaths and the deputy minister of health infected. There is no patient zero. Iran is now an epicenter and four new countries Iraq, Afghanistan, Bahrain and Oman have reported cases thought to be related to the rapid upsurge of cases in Iran. Given the capacity for transmission by asymptomatic cases, these new countries could become epicenters as well. Within four weeks South Korea has surpassed all countries as the country with the most cases outside China with a total of almost 1000 confirmed cases mostly due to in country human to human transmission. 231 of these were new cases in 24 hours with twelve deaths total. Iran, Italy and South Korea together are fast becoming the new epicenters outside of China. South Korea has no quarantine plans but has promised to undertake mass testing.
It seems the world is waiting and watching, nail-biting to see what will happen if it takes root in Africa. Although its healthcare infrastructure lags behind the world it is wields great experience in surveillance for poliomyelitis, cholera and Ebola virus and may be better prepared than other systems.
Ghana, located on the West Coast of Africa is a case in point. The country is ready for the first few 100 cases. A case load beyond 1000s may overwhelm the current strategic plan. In a phone interview, Dr. Franklin Asiedu- Bekoe the head of the Disease Surveillance Unit of the Ghana Health Service, reiterates that his team has the country’s plan down to a science but quickly notes that when there is a large outbreak there will be setbacks. Asiedu- Bekoe summarizes his interview by saying that addressing COVID-19 is going to be a partnership between the public and the healthcare system. It is interesting to note that this is one of the five commendations the WHO team made about the strategy in China, how engaged and compliant the public was. Ghana will to revert to and modify preparedness plans by virtue of recent outbreaks of Ebola, Lassa. The countries13 ports of entry, one by air, two by sea port and ten by ground is manned by Port health authorities. The major focus for COVID- 19 identification and detection has been at its state-of-the-art airport, Kotoka International Airport (KIA), where all passengers fill out a health declaration form supplemented by non-contact temperature monitoring. Testing is undertaken at the National Influenza Center at the Noguchi Memorial Institute for Medical Research. The National Influenza Center is headed by Professor William Ampofo, a seasoned virologist who closely works with the World Health Organization, and has been studying influenza virus and coronavirus trends in the region for years. He notes that all 20 tests on suspected patients have been negative. Since Jan 23, 2500 health declaration forms have been reviewed daily. Port health staff are equipped to identify and isolate travelers who meet criteria for screening and immediately detain them in holding room where an ambulance whisks them to one of the two designated COVID-19 ready treatment hospitals. One of the two hospitals, Tema General Hospital, has a 12 bed capacity for handling these cases and has the rooms equipped with negative pressure ventilation and ventilator equipment. The other hospital Greater Accra Regional Hospital (formerly Accra Ridge Hospital) has a five bed capacity for COVID- 19 cases but no negative pressure equipped rooms. Samples collected by trained staff are run in the virology lab housed in the National Influenza Center in Virology Department of the Noguchi Memorial Institute for Medical Research. This lab, which runs 5000 respiratory samples a year, has ten staff working 12-hour shifts with a result turnaround time of six hours on average. They have run labs at 1 a.m. before Asiedu- Bekoe noted.. In addition, Ampofo mentioned that another ten-member strong staff is on standby to run a 24-hour shift if needed. Ampofo adds that as an extra surveillance measure, all respiratory samples received in the center from Dec 2019 to date have been tested for COVID-19 and have all been negative. The center is running on funds designated for respiratory viruses, it will need at least $350,000 per year for equipment maintenance, staff salaries and lab supplies if it takes on this new directive to screen and identify COVID-19. It has yet to receive that commitment from the government to sustain its level of operations. At a second reference laboratory Kumasi Center for Collaborative Research in Tropical Medicine located in Kumasi, Ghana has established COVID-19 testing capacity while the reference laboratory at the Korlebu Teaching Hospitals can quickly be mobilized for testing if the demand calls for it.
One can be ready for a guest who announces the time of their arrival and is easily recognizable. Can any one country really be ready for a respiratory virus with high transmissibility and a long incubation period? Asiedu- Bekoe notes that despite their efforts and a well thought out plan Ghana still has much to do in the coming weeks to prepare for a pandemic as WHO as directed. The two treatment centers have a combined capacity of 17 beds and not all of them are equipped with ventilators. Two treatment centers is not enough for a population of 30 million whose daily interactions would create the perfect crucible for rapid spread from infected respiratory droplets. Each of the previously designated 10 administrative centers needs an equipped treatment center. Now there are 16 administrative regions. Port health authorities need training and retraining to recognize and isolate cases if and when they show up at any of the 13 ports. Customs and Immigration personnel will need to be trained. About 200 sets of personal protective equipment are available in each of the administrative regions. The real test of the capacity to identify, isolate, manage and contain infections will be dependent on the ability to detect disease if it comes to a small remote village in the northern part of the country hours away from the reference laboratory and eons away from any treatment center. He notes simulations are planned at the ports of entry and there is the need to plan simulations at various hospitals. The glue that will hold any of these lofty infection prevention measures in place is communication. Communication between the ports of entry, the research facility, the treatment centers and contact tracing personnel will be key to the success of all their efforts and plans. The country has held public lectures to educate and answer questions and separate myths from facts about the outbreak and a national COVID-19 hotline manned by seasoned epidemiologists has been established that will answer and address questions from patients and healthcare providers. All major media channels in print, audio and video are abuzz with information on the outbreak. Awareness is high. Simulations will need to be run several times over at the airports and hospitals on the actions to take when a suspected patient shows up. Every hospital or clinic needs to put up signage to alert patients with the appropriate travel history to report to the receptionist and isolated for interview. Three years ago, an outbreak of cholera in the nation’s capital Accra, with an estimated population of 5 million, about half that of Wuhan City, exposed the need for increased bed capacity in the economically thriving nation which is one of the eight countries with the highest growth in GDP for a couple of years in a row. An outbreak of more than a 100 cases of COVID-19 will greatly challenge the health system in a country where 2000 to 3000 doctors have to care for 30 million people.
China is still battling the outbreak but has set the bar high with the high technology driven interventions that were deployed when cases peaked from January 23 to Feb 2. During this peak new cases averaged 1000 to 2500 a day with 100 deaths a day per official figures. There are still 50,000 hospitalized patients. In the past week there seems to be a slight decrease in cases and in the on Feb 24 20 provinces reported no cases. The quarantine efforts imposed on 60 million people, the largest quarantine in the history of modern medicine has been ambitious, and yet there are now three epicenters. Should all the affected countries go on lock down?
Countries will also have to pay attention to the sea ports given the recent infection on two cruise ships off of the coasts of Japan and Hong Kong. A few of whom have been repatriated back to the US in a jet with several uninfected patients. This sharing of the same air system in a plane by the mix of infected and uninfected patients could potentially lead to an outbreak in the US given the clear evidence of transmission by asymptomatic patients
The outbreak will be contained if every country plans as though they would have a sudden outbreak of a few handful cases that will rapidly spread. The ideal preparedness plan should be able to detect this outbreak within a week, effectively isolate and treat affected patients while preventing healthcare worker transmission and be able to contact trace all exposed patients within the next week. It should have the capacity to diagnose 1000’s of cases at once; have the capacity to manage critically ill patients who would need ventilator support; and the capacity to keep recovered patients from infecting the susceptible populations. Is any country really ready?
Bertha Serwa Ayi, MD, FACP, FIDSA, MBA is an adjunct Assistant Professor of Medicine at the Nebraska Medical Center, USA and an adjunct lecturer at the University of Development Studies, Ghana. She is a graduate of the University Of Ghana Medical School (UGMS Class of 1996) where she graduated with honors and received the Alcon/Paracelsus Award in Ophthalmology. She completed her Internal Medicine Residency training at Good Samaritan Hospital Inc., affiliated with John Hopkins University School of Medicine in Baltimore Maryland in 2002. Furthermore, In 2004, she completed fellowship training in Infectious Diseases at a combined training program at Creighton University Medical Center, University of Medical Center and the Veterans Administration Hospital in Omaha, Nebraska. She is a Board Certified Infectious Disease Specialist and a fellow of the American College of Physicians (FACP) and the Infectious Disease Society of America, which produces this blog. She is in private practice.