Containment as an Ethiopian COVID-19 response is still relevant: a response to Daniel Hailu

The failure to contain the pandemic means efforts should be redoubled, not discarded

I read Dr. Daniel Hailu’s 21 July Ethiopia Insight article with great interest.

His firsthand experience of COVID-19 diagnosis and isolation in one of the treatment centers in Ethiopia, has given us a unique glimpse of how the system is running. I truly appreciate his effort and willingness to spend his time to give us this perspective.

The Ministry of Health (MOH) and others responsible for running the center have to take his comments and recommendations seriously and try to correct the living condition and logistic short comings of those places. In addition to the living condition, Daniel has made a number of critique and recommendations about the public health strategy that Ethiopia is following to combat COVID-19 pandemics.

Appreciating his astute observation and measured recommendations, I wanted to respond to some of the criticisms and recommendations he raised in his writing.

Public health in general and prevention activities in particular are usually victims of their success. What you prevent and avert, usually does not make news and is difficult to quantify. This is the reason for the apathy in funding prevention strategies. We introduce a vaccine for measles and what has been a deadly disease is now all but eradicated.

Unfortunately, there are many, who have the luxury of not knowing the disease thanks to effective vaccination campaign, leading the anti-vaccine movements.  The same can be said for an effective preventive strategy for COVID-19. What you prevent is difficult to measure and thus open for criticism.

COVID-19 is highly transmissible disease and thus any country whose strategy is solely on preventing community transmission is eventually going to fail. Ethiopia, as any developing country with limited capacity has accepted this fact and was working hard to mitigate the impact of a community transmission when it arrives.

Every single measure that have been taken since then including the flight closure, quarantine of arriving travelers, contact tracing and isolation, face mask and testing have made an impact on the community transmission and thus trajectory of the pandemic. How much is difficult to calculate but based on the earlier modeling estimates, it must be a lot.

Of course, things could have been better and at times should have been. We were slow in upscaling contact tracing, increasing the use of cloth face mask by the public and increasing testing. Those interventions would have further slowed the trajectory and dropped the actual number of cases that we are seeing now.

But to think that the containment strategy implemented by the country has now failed and of little impact cannot be further than the truth. If I have a criticism to make, it is for not upscaling the public health strategies quick and at unprecedented pace to match the dangers of the pandemics. This has not been done at the scale the pandemic requires, and remains to be a criticism to make.

Let us look at the facets of this program one by one:

Widespread community transmission

I agree with the paper that there is now a widespread community transmission particularly in Addis Ababa. Considering this, it is easy to assume there are a number of asymptomatic cases in the community transmitting and fueling the pandemics in Addis Ababa.

Unfortunately, the agreement we have ends here.

The best tested intervention a country can introduce when there is a widespread community transmission is increase testing, contact tracing and isolating contacts. The transmission of COVID-19 is such that on average, one infected person has a potential to infect three others during their illness. The only way to drop this is to isolate the patient early and interrupt potential transmission. Current doubling time in Addis Ababa is around 12 days. This means, every single infected case has a six percent chance of infecting a person daily. As the incubation period is 14 days, each day adds a potential 6 percent risk of transmission. An effective contact tracing will dramatically drop this by shortening the time a case remains in the community from the 14 days to as short as possible (depending on how quickly contacts are traced and isolated).

So, even in high transmission, peak of the pandemic times, still contact tracing and isolation will play a pivotal role though in the mist of such a high number of cases, it is often difficult to notice the impact of this critical intervention.  As Daniel has clearly identified, our contact tracing could have been much more rigorous and organized. Our estimate recommendation was at least 1,600 contact tracers in Addis Ababa and around 40,000 in the country. To date, we are way short of our target and this has clearly been the Achilles hill of our prevention, making this critical pillar of COVID strategy one of the weakest links.

Low per capita testing

Ethiopia has tested a little over 400,000 individuals since the detection of the first case in mid-March of 2020. Its daily capacity remains around 6,000 tests (there is a significant upscale of testing since the start of COMBAT campaign). For a country of over 100 million people, this is one of the lowest daily testing per capita. Having said this, there is another way to look at this low testing capacity. So far, over 70 percent of all cases are in Addis Ababa and testing is also predominantly done in Addis. Considering that, for a population of five million residents in Addis, the testing capacity is not as so desperate as it looks when the per capita is looked from country wide perspective.

As in many countries, the pandemic in Ethiopia is unfolding city by city and region by region. At this moment, sustained community transmission is seen in Addis. There is little evidence to suggest such is the case in regions. If that is true, without sustained community transmission, expanding testing just for the sake of increasing the number of tests is not a wise strategy.

Yield of each test is another way of looking at rationale of testing. As Daniel has clearly articulated, testing is critical to do contact tracing and isolation. He argues that at the current low rate of testing, without first increasing the testing capacity, contact tracing and isolation is not a rational approach. I look at this from a different angle. Countries, who have controlled COVID-19 effectively have reported at a minimum 30 individuals contact traced for each positive case identified. If we were to saturate that, then without increasing testing, upscaling contact tracing might not bring the intended benefit. At this time, Ethiopia is contact tracing around six individuals for each positive case identified. This leaves so much room for our system to improve. For this reason, until we achieve that minimum required contact traced per tested number, even at the low testing capacity, tracing and isolating contacts remains a critical pillar of our public health strategy.

Isolating infected persons

1. Management: Daniel has got this point quite right. I urge the MOH to look at the isolation centers and address the shortcomings identified by Dr. Daniel. COVID -19 patients in isolation are potential cases that could transmit disease and unless proper isolation precautions are taken, we will expose health care workers and others who are interacting with patients.
2. Testing and retesting- based on published literature, the guideline on when to stop isolation and discharge COVID-19 patients has been changing. The current recommendation from Center for Disease Control has made this clear and simple. COVID-19 cases who have remained in isolation for 10 days and have been asymptomatic for over 24 hours have to be discharged without a need of test to confirm clearance. This should be the guideline in Ethiopia’s isolation centers.
3. Implementation of the case record form: Daniel’s observation on this is both powerful and disheartening. We remain dependent of data from other countries because we do not carefully document our own observations and create a local relevant data. Our paper-based data collection in the era of digitalized world is one of the disappointments of our system. His observation, recommendation and critique have to be taken positively and changes must be implemented immediately.
4. Meeting nutritional needs and preference: again, I applaud Daniel’s observation on this. A quick and substantial arrangements must be done to correct the delivery of proper nutrition. As the numbers of patients to be isolated increase day by day, this is going to remain a challenge for a country which has limited financial capacity. The cliché that more patient will die of non-COVID issue than COVID while on isolation could become a reality. Considering this, for COVID-19 cases with mild symptoms, transitioning to home-based isolation should be a priority to decrease the burden in the system.

COVID-19 is a pandemic that the likes of our generation have not seen. It has devastated countries in its path. The interventions that are tested and known to mitigate the pandemic, though simple and primitive at times, are immensely expensive. Quarantine and isolating thousands of suspected individuals and patients and attending to their daily need for 14 days is a huge task for any country. Ethiopia is not different in this regard. What is to be critiqued here is clear. Upscaling contact tracing, digitalizing data collection, improving the conditions at the quarantine and isolation sites must take urgent attention.

The economic challenge and political unrest the country is facing should not be a reason not to improve the system. Every effort should be implemented to flatten the curve and ultimately decrease the number of total infections. Considering the limited tertiary health care system, the country has, upscaling of the hospital care to address this pandemic, as noble a cause as it is, cannot be a coherent and viable strategy.  The economic recovery depends on a good public health strategy.

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