The Senior Doctors who are stationed at the various Central Hospitals in Zimbabwe would like to bring to your attention areas that are of concern with regards to the current approach in the management of the Covid-19 pandemic. We acknowledge the work that has gone into getting Parirenyatwa hospital and other facilities around the country ready to receive Covid-19 patients. We also applaud the improvement in availability and turnaround time in testing for the disease.
Reduction of Mandatory Quarantine from 14 days to 8 days for Returnees from Covid-19 Hot Spots
As SHDA, we applaud the policy of mandatory testing and quarantine of all returnees coming from hotspots. We are however concerned with the reduction of the quarantine period to an effective 8-days which is contrary to the scientific evidence and is outside the World Health Organization (WHO) recommendations. The quarantine period is clearly guided by the incubation period of the virus, which has been proven scientifically to be between 2-14 days. Regionally the mandatory quarantine for travelers from Covid019 hotspot countries ranges between 14-21 days. South Africa has a mandatory quarantine period of 21 days; Botswana 14 days; Zambia 14 days; Mozambique 14 days. And no other country has attempted a quarantine period of less than 14 days. While some countries have implemented self-quarantine on its returning residents, we feel this is not easy to implement in our setting due to compliance challenges that have been observed so far, the challenges of policing such an arrangement and lack of trained personnel who can attend to large numbers of returnees in their homes.
Regarding the use of Rapid Diagnostic Tests (RDTs) for Covid-19
While testing on suspected cases like the returnees, the RDTs rely on the detection of antibodies made by the patient in response to an infection by the Covid-29, and thus do not detect the virus per se. Patients can take between 7 to 12 days to make antibodies. Meanwhile, Covid-19 infected patients are highly infectious during this early phase of infection. Therefore, relying on the RDTs in the early phase of infection would be inappropriate since cases of Covid-19 missed thereby putting communities at risk of Covid-19 infections. Ideally, RDTs should be used for surveillance and not diagnosis. The aim as far as returnees are concerned is to diagnose which is supposed to be done by Polymerase Chain Reaction (PCR), which is currently considered the ideal test for Covid-19.
Quarantine Facilities
The WHO International Health Regulations (2005) recommends that a quarantine facility be fully respectful of the dignity, human rights and fundamental freedoms of persons. We greatly appreciate the stand taken by the Ministry to impose quarantine on all returning residence from Covid-19 hot spots. The Ministry should go a step further in enlightening the returning residence on the need for quarantine and have returnees prepared accordingly. There has to be provision for the basic needs including food, water and accommodation. It is also the right of returning citizens to receive health care, social and psychological support. The facilities should provide for social distancing, face masks, gloves, adequate ablution facilities with running water and regular disinfection of surfaces. It would be way cheaper for our government to provide these needs to healthy individuals as compared to treating Covid-19 cases that would emanate from acts of omissions. As you are aware, the cases of Covid-19 we mainly have so far are imported cases and their contacts. We believe that in our setting, if we can minimize early exposure of our communities to individuals who are coming from hotspots, it is still possible for infections to get to zero in the shortest possible time.
Availing of Laboratory Confirmed Results
We commend the government for decentralizing testing to Mpilo Hospital and implore that more centers be opened. We are however concerned with the long turnaround time for results. There are reports of incidences whereby positive Covid-19 results are flighted first on social media platforms without the affected patients being informed of their results and having received appropriate counselling. In some of the scenarios, suspected cases waiting for the PCR test results will have been told to go home and wait for a phone call to avail their results. With the current decentralization of services, the Ministry can utilize the available counselling services from counselors, nurses and doctors in the different units to take part in availing results. Some training on Covid-19 results divulging may also help build confidence in the colleagues. This can be done through webinars. We would strongly urge the Ministry to provide face masks to suspected cases whilst they await their results and the second PCR test. We realized the turnabout time for the PCR results still remains at 2-3 days. This can be improved. It would also foster confidence if PCR and RDT results were reported separately.
Isolation of Confirmed Cases
As of the 26th of April 2020, we noted that we have a total of 25 active cases of Covid-19. The approach by the Ministry has been to allow Mild cases to isolate in their homes and the moderate to severe cases are supposed to be admitted to hospital. We would like to note that this has been a blanket approach to the care of Mild Covid-19 positive cases. There must be prior home visits by Social Workers to assess suitability of the homes of the Mild Covid-19 positive cases. Many of the urban middle-class and poor families may not have the capacity to safely self-isolate at home. For Mild Covid-19 positive cases whose homes are not suitable for isolation, such patients should be isolated in a government-mandated facility. It is cheaper for the government to isolate the active cases that we have at the moment until full recovery i.e. having two negative PCR tests on separate occasions. We also advocate that the patients on isolation continue to take their other medications for any comorbidity and have regular health checks, social and psychological support whilst in isolation.
Care of Contacts of Covid-19 Patients
Community testing and Contact tracing is a critical component of combing the Covid0-19 pandemic. We urge government to ramp up testing particularly targeting our hot spots of Harare, Bulawayo, Victoria Falls, Beitbridge and Mhondoro and put in place an effective mechanism to trace and test all contacts. We feel the current lock down that has been instituted by the Government presents an opportune time for the Ministry to carry out tests in communities where there have been a cluster of cases.
Human Resource Base
We strongly urge the Ministry to address the perennial human resource issue, otherwise all the good work into the preparation of facilities will not yield the desired result. All qualified personal need to be harnessed, including those who are currently not employed by the Ministry of Health and Child Care. We have supernumeraries in our midst who continue to contribute tirelessly in the fight against Covid-19 yet they continue to have no salaries. There are University of Zimbabwe lecturers who have not been paid their clinical allowances for many years. The unresolved issues of working hours for nurses continue to undermine service delivery and quality of care in our health facilities. We urge the Ministry to take this opportunity to highlight the need for proper renumeration for all health workers so that proper service delivery can be restored.
Role of Private Facilities
The Senior Doctors greatly appreciate the work being done by private hospitals in the fight against Covid-19. We are of the opinion that the private facilities should operate in a coordinated and accountable fashion. We implore upon the MoHCC to ensure that these activities are coordinated, there is sharing of data and that Standard Operating Procedures for Covid-19 are adhered to at all times at these facilities.
Upscaling of Testing
We have noted the great efforts being done by the Ministry of Health and Child Care in ensuring that tests are being done at the major health facilities. We do urge the Ministry to make use of this time during lock down to maximize on testing and identification of Covid-19 cases; the current lack of testing at community level might prove to be a missed opportunity in the long term.
Mandatory Wearing of Masks in Public Places
The Covid-19 virus is spread via droplets; we also tend to have a lot of asymptomatic careers within the young and middle aged members of society. Scientific evidence has greatly shown that if face masks are worn correctly, they greatly reduce the chance of transmission of the Covid-19 virus via droplets. We would also like to urge the government to look at ways of subsidizing the cost of these face masks so that the public is able to afford face masks.
Conclusion
As the Senior Hospital Doctors Association, we would like to commend all the efforts that the Ministry has put in the drive to combat the Covid-19 pandemic. It is critical at this stage of our pandemic curve to institute robust, scientifically sound measures in testing, identification/isolation and contact tracing. Our best chance is containment, mitigation and instituting best practice in the management of Covid-19
Source: Senior Hospital Doctors Association (SHDA)
