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Friday, August 7, 2020

Why quarantine measures should be scaled up and recommended discharge criteria for recovered individuals with Covid-19

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By Dr. Manal Ghazzawi

Before launching into the subject ahead, I would like to state clearly that I speak from the perspective of an industry professional and only state facts in this article with the aim of achieving one objective, which is the wellbeing of our people and our nation. I would like to commend all stakeholders for their preparedness and response in the fight against this mysterious virus. However, more needs to be done, as even the best health care systems in the world are overwhelmed with the management of Covid-19 cases, and many lives have been lost.

We all know the steps the MOHS have taken to quarantine individuals, however if not implemented properly, it may also create additional sources of contamination and dissemination of Covid-19 in the future. I want to focus in particular on quarantine procedures that should be followed in cases of community transmission of the virus after contact tracing. I am particularly concerned about future quarantine measures of communities.

According to the World Health Organization (WHO), and before implementing quarantine, countries should properly communicate and socialize such quarantine measures to the general public, in order to reduce panic and improve compliance:

  • Authorities must provide clear, up-to-date, transparent and consistent guidelines, and reliable information about quarantine measures. Also taking into consideration all types of living conditions including informal settlements.
  • Constructive engagement with communities is essential if quarantine measures are to be accepted.
  • Persons who are quarantined need to be provided with health care, financial, social and psychosocial support, basic needs and other essential requirements. The needs of vulnerable populations should be prioritized
  • Cultural, geographic and economic factors affect the effectiveness of quarantine. Rapid assessment of the local context should evaluate both the drivers of success and the potential barriers to quarantine and inform the design of the most appropriate and culturally accepted measures.

Social media have been awash with videos of several challenges faced by the first batch that was quarantined. Being in quarantine, though necessary, is in itself quite difficult, especially for the old, the sick, those living in informal settlements and otherwise vulnerable groups. The following recommendations help alleviate their situation and protect our nation:

  • Initially, proper communication with regards to rights of these individuals; provisions that will be made available to them; how long they will need to stay; what will happen if they get sick; contact information of their local embassy or consular support (for foreigners) must be done.
  • Education on physical distancing within quarantine facilities should be emphasized which is the main reason why quarantined individuals infect each other.
  • Dedicated logistics teams with the appropriate knowledge and skills must segregate and coordinate quarantined individuals and avoid over-crowding in vehicles used to transport them. If quarantined individuals are all packed in one vehicle there is high risk of transmission of the virus to uninfected individuals. That was the case among those quarantined when arriving from abroad.
  • Experienced health personnel with the right communication skills should visit quarantine centers at least twice daily to answer questions and render psychosocial support to quarantined people. Apparently the MOH is doing so but from what I understand, not much service is actually rendered.
  • Special considerations should be given to older individuals and individuals with co-morbid conditions who are at an increased risk of severe COVID-19 disease. Elderly quarantined people need mobility support and there is a chance of them running out of essential drugs to manage their chronic disease.
  • An in-house trained nurse should be available to render support in case of an emergency to elderly with comorbidities like diabetes and hypertension.
  • TRAINED Mental Health nurses are to visit these facilities every day, but sadly enough we don’t have enough in the country. The few that we have are overwhelmed with psychiatric issues from our substance abuse epidemic and other traumas. Because of this shortfall health care workers or social workers should be trained to offer psychosocial support to make quarantined individuals feel much better mentally and emotionally.
  • Members of staff working in these hotels should have be trained on infection control and prevention (IPC) to ensure that the environments are being kept clean and they follow disinfecting procedures.

We are seeing infections with SARS Cov-2 among quarantined individuals because quarantine measures have not been properly put in place, best practice of IPC measures were not being implemented. It is worrisome that quarantine measures were only implemented later after many individuals had already arrived from Europe and other countries that are heavily affected. The 13th Covid-19 case that was hospitalized on the 15th of April, arrived on the 13th of March before quarantine measures were implemented; hence doing contact tracing with all individuals case 13 have come in contact with after all this while becomes a big dilemma. Community transmission will emerge very soon and most likely with exponential increase and  we do not have the capacity to test them all. More the reason why we all need to take precautionary measures, these contacts being silent carriers of the virus are spread everywhere and not all of them can 100% be traced and tested. Covid-19 is an imported disease among the affluent or those that are financially stable to travel, hence those that can for example afford to visit expensive restaurants are mostly the silent carriers infected possibly by those who arrived before quarantine measures were implemented. With this in mind, I would suggest that government closes all restaurants and bars in the country and allows for take away food only as many individuals are still visiting restaurants at the beaches and others. This will unfortunately affect employment and the country’s economy which is not a news to us as this is the inevitable happening globally to protect our nation.

Partial lockdown will create some impact, but it is not quite enough, sadly. Many Sierra Leoneans gather for transportation to get to their homes and physical distancing is not being adhered to. Lack of physical distancing gets worse when people are rushing to go home before the curfew. Market women gather in clusters to sell. This is just too overwhelming; I am afraid of what awaits us in this country. We are not to create panic, but from the way I see things, it is panic that will allow us to adhere to health regulations and comply to what government advises us to do.

Persistence of the virus in recovered patients

SARS-CoV-2 virus can initially be detected 1–2 days prior to symptom onset in upper respiratory tract samples; the virus can persist for 7–12 days in moderate cases and up to 2 weeks in severe cases (WHO mission to China Report). In faeces, viral RNA (genetic component of the virus) has been detected in up to 30% of patients from day 5 after onset and up to 4 to 5 weeks in moderate cases. The significance of faecal viral shedding for transmission still must be clarified.

The public have been asking how come there are no recovered patients yet among those infected with SARS Cov-2. Many discharge guidelines have been produced from re-known health institutions. For example, China Center for disease control and prevention days patients meeting the following criteria can be discharged:

  • Afebrile (i.e. having no fever) for >3 days,
  • Improved respiratory symptoms i.e. no coughing or signs of pneumonia
  • Normal lung imaging with no signs of inflammation
  • Negative test for the virus in respiratory samples twice consecutively (sampling interval ≥ 24 hours).

After discharge, patients are recommended to continue 14 days of isolation management and health monitoring, wear a mask, live in a single room with good ventilation, reduce close contact with family members, eat separately, keep hands clean and avoid outdoor activities.

It is recommended that discharged patients should have follow-up visits after 2 and 4 weeks

The above are what clinicians treating Covid-19 patients do before discharging any infected individual  and this might answer the question why there are no recovered patients released as yet.

On this note I suggest we show appreciation to all front-line workers in the fight against this disease, they are working very hard to bring this to an end. The government need to motivate them all, especially the nurses who are volunteers and at times spend sleepless nights in hospitals.

Risk of re-infection among those recovered

There is a bit of a catch here. Normally, when we are infected with a microbe the body mounts an immune response and develop memory cells that will fight against that infection when it comes back. In the case of an infection with SARS CoV-2, scientists have realized that some recovered individuals have developed high immunity against the virus and some have not. Up to 111 of recovered cases have been readmitted in South Korea after testing  positive again for the virus. This might not be as a result of reinfection but due to lingering effects of the virus i.e. possibly reactivation where it was not cleared initially in the body or tests were not able to detect the virus for a period of time. However, it is also known that after viral infections, the genetic material of the virus persists which can create a positive test even though patients might be asymptomatic. The next question here will be, do recovered patients have the tendency to spread infection? The answer is, there is a possibility of a recovered person not being infectious i.e. spread the infection despite testing positive, however researchers are not sure if there is a possibility of a rebound infection or re-infection. Conclusive evidence about sufficient immune response is yet to be verified to prevent resurgence of the pandemic.

WHO noted that more than 300,000 of the 2 million coronavirus cases across the world have recovered but scientists are yet to understand antibody response, and whether there is immunity to the infection and for how long. Until we have clarity on this aspect, we cannot lift restriction bands or life cannot go back to normal where physical distancing is not maintained. This is telling us that this virus remains a mystery to all of us hence we should continue to adhere to health regulations and seek proper health care if you notice you are sick. Scientists believe Covid-19 will continue to clatter across the world in waves, hitting the same countries multiple times. This is also a call to action, that we should persistently indulge in adoption of healthy lifestyle to continuously boost up our immune system and not wait till there is an outbreak of a disease. Among healthy lifestyle choices are; to eat healthy (make sure you eat fruits and vegetables every day); exercise at least 4 times per week; avoid or limit intake of alcohol and other practices that predisposes you to sexually transmitted disease or infectious diseases that will compromise your immune system.

We are all in this together, I strongly advice the elderly and especially those with diabetes, hypertension, kidney disease, heart disease, mothers with asthmatic children to be very extra cautious. STAY HOME PLEASE, only go out when it is really necessary. Also do not self-administer chloroquine, there are no conclusive evidence of its use for prevention and treatment of Covid-19. I particularly advice diabetic patients not to consume it as it has shown to cause severe hypoglycemia (reduced blood sugar level), this could be fatal especially among those taking hypoglycemic drugs. Chloroquine is also known to be toxic to the eyes and heart.

Dr. Manal Ghazzawi is a Consultant Clinical Pharmacist, Chief Executive Officer of CitiGlobe and founder of KnowHep Foundation.

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