By Dr. Manal Ghazzawi
As of today 26th May 2020, Sierra Leone records 754 cumulative confirmed positive Covid-19 cases, with a cumulative recovery of 297, and 42 deaths. At this point, it is worrying that we have such a high death rate in Sierra Leone, the highest out of all Mano River Union countries. Can we say it is only due to underfunding by the Ministry of Health and sanitation of Sierra Leone of the public health response system? Is it due to denial by the public that the virus really exists due to inadequate risk communication? It is sad that even before recording the first case in Sierra Leone, we were not really prepared, despite the lessons learnt when Sierra Leone was ravaged by the Ebola outbreak.
I could vividly remember asking a world public health leader of the UK Public Health Rapid Support team “Do you think Sierra Leone is ready to handle another outbreak?” His answer, sadly, was “No”.
We had ample time to have been well equipped in all areas the moment WHO announced Covid-19 to be a pandemic disease, more so when his excellency the president mentioned “It is not a matter of if, but when will Covid-19 reach Sierra Leone”, and he also stated in another speech “We believe as a Government that the best way to deal with a crisis is to prevent a crisis and that the best time to deal with a crisis is to plan well-ahead of that crisis. And that is what we are doing”. I will not go ahead to dwell over spilled milk, but I will say, as a matter of fact, if the government and all Sierra Leoneans do not step up to make a concerted effort in this fight, we are yet to see worse.
Situational Analysis in Sierra Leone
Africa has recorded more than 100,000 cases and, fortunately, Africa’s low mortality rate associated with COVID-19 may be attributed, in part, to 60% of the continents’ population being under the age of 25, according to early analysis by the WHO.
Conferring to the case management pillar of the Emergency Operation Center (EOC) and looking at age and gender distribution as well as comorbidities of those dying of Covid-19 in Sierra Leone, so far-the death rate recorded among males between ages 20-39 years is 9%, 40-59 years is 47% and 60-79 years is 46%. On the other hand, for females between ages 20-39 years the death rate recorded is 22%, 40-59 years is 22% (death only occurred at ages 45-59 years) and 60-79 years is 55%. Generally, more males are dying than females and mortality is more prevalent among age brackets 55-59 years and 75-79 years. Out of all these deaths, as much as 84.6% have comorbidities, while 10.3% have no comorbidities, and 5.1% are unaware of their comorbidities. Approximately 36% are dying as a result of diabetes, 33% as a result of hypertension, and 16% as a result of HIV. However, Covid-19 deaths among those with hypertension fell at ages 50-69 years. Mortality is hence more prevalent among age brackets 55-59 years, 75-79 years.
What other countries in the region are doing that we are not doing
Senegal is emerging as one of the world’s leaders in the fight against COVID-19. In April, the country has seen a decrease in the number of hospitalized Covid-19 patients. Senegal’s coronavirus-related deaths remain low, and the country has clocked the highest rate of recovery of coronavirus patients in Africa. In March, Senegal embarked on a validation trial on a rapid diagnostic test which only costed their population 1$ to get tested for mass screening exercises that helped with timely identification and response. Ghana is also following a similar trend where hundreds of thousands of people have been tested so far. Senegal even created robot doctors to prevent transmission of the virus to health care workers. They went further than so many countries in Africa with an innovative app that can provide its public with factual information to mitigate the risk of the spread of fake news – this app is helping to empower its citizens to ensure they are kept abreast of the latest news in this rapidly developing situation. Where are we in Sierra Leone when it comes to research and development (R&D) or to rapidly develop innovative solutions? We are way behind; it is high time for the Government to support and invest in R&D that could not only help in this fight but with the inevitable, potential outbreaks in the future.
Challenges faced causing increased mortality
According to the case management pillar, the first 72 hours of care is overly critical to averting mortality, and that critical care needs availability of quality drugs and other emergency care packages. A senior pharmacist mentioned that “ordinarily in the absence of Covid-19 most patients will pay out of their own pocket for their drugs, the drugs available in the custody of the Government of Sierra Leone are mainly free health care drugs i.e. those for reproductive health and global fund supported commodities (such as those for malaria, TB/leprosy and HIV drugs and related supplies). Limited supplies of the free health care drugs is being utilized in the Covid-19 response so far, the main donor prefers that these products are not being utilized for this purpose as the beneficiaries of the initiative would eventually continue to need their supplies with or without Covid-19”. This has led to doctors actively involved in this fight even pay out of their pocket to support some Covid-19 infected patients at the treatment centers, more so when basic life-saving drugs are not available the moment it is desperately needed.
On this note, this has led to immense pressure in the “already fragile health system”, to cater for free to the most vulnerable populations that are severely or potentially affected by Covid-19. Notwithstanding that, apart from the lack of a health infrastructure and all resources needed to save lives, there are many social and behavioral issues causing increased death. The fact that Sierra Leoneans are in constant denial about the existence of Covid-19 in the country, will continue to lead to the asymptomatic spread of the infection. Those who believe Covid-19 exists, are scared to visit hospitals currently and tend to self-medicate either appropriately or inappropriately. There is dire need for research to reveal the secret behind nosocomephobia (fear of hospitals) during an epidemic. Is it due to the lack of trust of the health system? The Ebola outbreak has left many Sierra Leoneans with post-traumatic stress disorders and unrealistic beliefs and denial, and the same trend seems to be continuing with Covid-19.
Addressing Covid-19 related stigma involves a concerted effort by both, the community and public health officials to assess what people know and don’t know about the disease; to help identify stigmatization; partner with community leaders and groups to address stigma; develop and conduct public messaging and community campaigns to fight stigma; implement practical interventions, skills-building training, and other educational programs to reduce stigma; and last but not the least to evaluate stigma-reducing efforts.
Since diabetes and hypertension are chronic conditions that become a full-time job for affected patients, the tendency for depression to occur is inescapable which could potentially lead to non-compliance to medication. During this pandemic, it is of utmost importance that health care professionals offer patient education on diabetes and hypertension, especially concerning the importance of regular monitoring (of both blood sugar levels and blood pressure), lifestyle modifications, and medication adherence. This will go a long way in preventing complications of both diseases that have become Covid-19’s “best friends”.
In these crucial times, it is a matter of must for both males and females, aged 50 years and above with hypertension and/or diabetes to regularly monitor their conditions at home, eat healthy and exercise. Those with prevalent chronic communicable diseases like HIV, TB and/or Hepatitis B should adhere to their drugs or treatment plan since their immune system is compromised. Among those at risk of contracting hepatitis B, vaccination is key. The use of condoms are highly necessary to prevent sexually transmitted diseases which in turn predisposes you to having HIV. Many researches have confirmed increased surge of HIV cases in the next 2 years, contracting HIV during this pandemic can also increase likelihood of becoming infected with the novel corona virus. Those with respiratory diseases like asthma should avoid triggering factors that might aggravate their situation and regularly take their medications for treatment and prevention of asthmatic attacks.
Most cases arriving at the hospital are deteriorated cases reaching late due to poor health seeking behaviours – this has been the main cause for deaths occurring especially at Connaught Hospital. Poor health seeking behaviours might however not be the only reason but lack of swift response by 117.
The overburdened health care system will face a drastic reduction in mortality rate if vulnerable populations help themselves be more vigilant about their health.
This fight is only ours; it is a matter of “us” and not “me” let us work hard every day to stay safe and save lives.
Dr. Manal Ghazzawi is a Consultant Clinical Pharmacist, Chief Executive Officer if CitiGlobe and founder of KnowHep Foundation.