Overview of COVID-19 Response in Kaduna State, Nigeria, March-July 2020
Gregory C. Umeh1, Dauda M. Madubu1
1World Health Organization, Nigeria
Correspondence
Gregory C. Umeh
World Health Organization
Nigeria
E-Mail: [email protected] Background
The last six months have seen concerted efforts by government, development partners, communities, and individuals to contain the spread of the COVID-19 pandemic. COVID-19 has wreaked havoc in all the continents, from Asia, Europe, Africa, America to Australia.1 The first case of COVID-19 was reported in Wuhan, China, in late December 2019.2 The patient presented with cough, catarrh, difficulty in breathing, fever, and body weakness, which were consistent with the features of atypical pneumonia, and was managed symptomatically. The rising morbidity and mortality in Wuhan in December 2019 and early January 2020 led the World
Health Organization (WHO) to declare the novel disease (COVID-19) as a public health event of international concern (PHEIC).3 The WHO activated the international health mechanism and response and national and regional health authorities instituted measures to limit the spread of the epidemic from China to other countries.3 The exponential rise in cases in the first quarter of
2020 led to the WHO classification of COVID-19 as a pandemic, and the activation of the
International Health Regulation (IHR), 2005 guidelines.4,5 The morbidity of COVID-19 is 17,
064, 064 globally, and 668, 073 people have died from the complications, as of 31 July 2020.6
Nigeria recorded its first case of COVID-19 on 27 February 2020.7,8 The index case was an
Italian who flew to Lagos from Milan on a business trip. He had a fever, cough, and body weakness 2 -3 days after arrival in Nigeria. He presented at the company’s clinic and was interviewed, examined, and treated, but days after refereed to another facility because his condition deteriorated. The referral hospital isolated him and screened for COVID-19, and the test turned out positive. He received symptomatic and supportive treatment and made a full recovery and was subsequently discharged. Nigeria has recorded 43,151 confirmed cases and
879 deaths of COVID-19 as of 31 July 2020.7
Kaduna State, the former headquarters of the defunct northern region, with a total population of 10 million citizens, has recorded 1,457 confirmed cases and 21 deaths of COVID-19 as of 31
July 2020.7 The index case, the state governor, who was exposed to COVID-19 patients in the nation’s capital Abuja, tested positive to COVID-19 on 28 March 2020. He was isolated and managed symptomatically, and subsequently discharged after full recovery.
COVID-19 has varied presentations, which can be mild to moderate, severe, or critical.9 The majority of the patients presented with mild to moderate symptoms, and many recovered fully with or without treatment. The incubation period of COVID-19 is 2-14 days, with an average of
10 days.10 COVID-19 is transmitted from an infected to a non-infected person through droplets.11
Some of the confirmed cases of COVID-19 showed no signs or symptoms of the disease.12 The mortality of COVID-19 is higher among the elderly and individuals with underlying comorbidity, for example, diabetes, hypertension, heart disease, etc.13 The diagnosis of COVID-
19 is a laboratory, and the gold standard is the Polymerase Chain Reaction (PCR) test.14 COVID-
19 cases are better managed in isolation centers, with facilities for resuscitation and intensive care.15 The use of Hydroxyl-chloroquine, Azithromycin, and retroviral drugs is on the rise, and empirical studies have shown benefit over placebo.16 COVID-19 has no cure, and efforts to develop a vaccine are preliminary, so prevention remains the best choice to contain the spread of the virus.17
In line with the national guidance, Kaduna State activated the COVID-19 Emergency
Operating Centre (EOC) with the confirmation of a case to coordinate the response. The EOC developed an Incident Action Plan (IAP) with nine strategic pillars, including coordination, surveillance, and epidemiology, Infection Prevention and Control (IPC), case management, risk communication, logistics and supplies, laboratory, the point of entry, and research.18 The EOC also trained various cadres of health care workers across the state, including volunteers and partners, set up treatment and isolation centers, and four (4) functional laboratories.
Interventions
The WHO has promoted the use of non-pharmaceutical measures, like, regular handwashing with soap under a running tap for at least 30 seconds.19 The use of alcohol-based sanitizer to disinfect hands, social distancing, use of facemasks, gloves (personal protective equipment), self- isolation, the lockdown of cities, environmental decontamination, and waste management to limit the spread of COVID-19 from person to person and from cities to cities, and countries to countries, are standard practices.17,20 The key to prevention is an effective combination of different non-pharmaceutical measures by citizens and authorities, through appropriate risk communication of the danger of COVID-19.21
Infection Prevention and Control
Handwashing: handwashing is a proven measure for control of contagious diseases, like
COVID-19.19 Many studies have shown that handwashing, in combination with other non- pharmaceutical measures, is very useful and can reduce transmission by over 80%—the WHO has vigorously promoted handwashing at homes and all public places like the hospitals, markets, business premises, etc.21,22 handwashing should last for at least 30 seconds with soap and running water. At the health facility, there are five moments for handwashing, namely before coming in contact with a client or patient, after examining a patient, after touching the patient’s surrounding, after contact with the patient’s excretion or waste, and before examining another patient.23
Hand sanitizing: people are encouraged to disinfect their hands with 70% alcohol-based sanitizer, especially when in transit or if soap and water are not readily available for handwashing.24 The alcohol-based sanitizer comes in different sizes and is handy to carry in pockets or handbags.
Social distancing: COVID-19 is a massive droplet infection, and usually deposited not more than 2 meters from where it is shedded.25 The World Health Organization has promoted social distancing as a beneficial measure to break COVID-19 transmission since the coronavirus is a massive particle and requires human contacts to move from person to person.26 Social distancing limits physical contact between individuals and denies the virus the human link necessary to sustain the transmission.
Personal Protective Equipment (PPE): the use of PPE in a health setting is very crucial in the management of COVID-19 cases.27 The health worker must correctly wear the appropriate
PPE during the interview, sample collection, and treatment of COVID-19 patients.28 The choice of PPE depends on the risk assessment and the level of exposure of the clinician or health worker.29 The PPE comes in different forms, from surgical gloves, elbow rubber gloves, facemasks, face shields, goggles, boots, apron to N95 respirators.27 The use of facemask or covers in public is compulsory in Kaduna State because of the fear of community transmission.
The amended quarantine law of 2020 in Kaduna State makes it a criminal offense for a citizen to appear in public without a facemask. The quarantine law stipulates punishment ranging from fine to community services after successful conviction by a mobile court.30 Lockdown: lockdown is an essential measure in the control of COVID-19 transmission, especially in larger cities where social distancing is very difficult to maintain. Lockdown is a compulsory restriction of movement except for those on essential duties by the government.31
The Kaduna state-enforced total lockdown for 75 days to stem the rise in COVID-19 and prevent community transmission.32
Administrative measures: administrative measures implemented by the government apart from lockdown were isolation and treatment of confirmed cases in approved government facilities. The compulsory use of facemask or cover, expansion, and renovation of isolation centers, scaling up of testing facilities, two more laboratories approved by the Nigerian Centre for Disease Control (NCDC), procurement of more PPE for health workers, and budgeting and approval of fund to support COVID-19 response.33
Environmental decontamination: the government decontaminated public places, markets, offices, hospitals, motor parks with chlorine-based solutions. Environmental decontamination is an essential tool in the control of COVID-19 spread, as fomites left on the surface are destroyed or rendered inactive.34
Waste management and safe burial: Appropriate management of waste generated in hospitals, clinics, isolation centers were enforced. The wastes were incinerated or burn and buried at secure sites.35 The burial teams were also trained and given the PPE and logistics to conduct a safe and dignified burial of COVID-19 deaths.36
Point of Entry
The point of entry pillar coordinated the mapping of entry points and screening, isolation, and notification of suspected COVID-19 cases from neighboring states. Kaduna State has 35 entry points for passenger screening on COVID-19. The state government, through the Rural Water and Sanitation Agency (RUWASA), provided handwashing facilities (plastic bucket with taps, soaps, hand sanitizers) at motor parks and border towns.
Risk Communication
The risk communication team conducted many activities to inform, educate, and enlighten the public on the COVID-19 pandemic. The activities included production and distribution of posters and banners, radio and television jingles and messages, roadshows, advocacy to religious and traditional leaders, and sensitization of the media.
Surveillance and Epidemiology
The surveillance and epidemiologic pillar consist of alert and rumor, case investigation, contacts tracing, and data teams. The surveillance team has investigated 8,915 suspected
COVID-19 cases, of which 1,457 (13%) were confirmed positive. The contact team has identified, line-listed, and followed up 4,050 contacts of confirmed COVID-19 cases March-July
2020.
Laboratory
Kaduna State has four functional laboratories accredited by NCDC to conduct the test for
COVID-19. The laboratories are DNA Lab, Kaduna (a private lab); Ahmadu Bello University,
Zaria; Yusuf Dan Tsoho Memorial Hospital Kaduna, and Mobile laboratory (Wellness on
Wheel). The four laboratories have conducted 11,583 tests (initial tests). The interval between sample collection, test, and receipt of results by patients is 2-3 days.
Case management Confirmed COVID-19 cases were isolated in the approved isolation centers for supportive and symptomatic treatment.37 The state has five isolation centers, Kaduna Infection Disease and
Control Centre (IDCC), Hamdala Motel, Kaduna and Ahmadu Bello University, Teaching
Hospital, Zaria, Zaria Hotel, and Kafanchan School of Nursery. The patients received a cocktail of treatment, which include Hydroxychloroquine, Azithromycin, and retroviral drugs.38
Logistics and Supplies
The logistics team kept all inventory of supplies and commodities for the state COVID-19 response. The logistics team issues commodities to the different pillars and maintains a daily balance of items and responsible for initiating procurement when stocks are low. The Kaduna
State government has spent over $5 million in support of COVID-19 response.
Coordination
The Kaduna State Deputy Governor chairs the expanded state Emergency Operations Centre
(sEOC) that consists of representatives of many stakeholders: government ministries, departments and agencies; religious and traditional leaders; development partners, security agencies, civil society organization, and the press. The state Commissioner of Health serves as the deputy chair, assisted by the Permanent Secretary, Director of Public Health and State
Epidemiologist. The sEOC coordinated the activities of all the pillars and held daily virtually meeting over Zoom, since the outset until date.
The Kaduna State government has provided political and financial support to the COVID-19 response, through the emergency appropriation of funds and leadership by example. The State
Governor has interacted on many occasions with the public through live media chats, appeared on radio and television to narrate his experience as a COVID-19 survivor, and encouraged them to adhere to the preventive measures.
Achievements
The combination of measures, both pharmaceutical and non-pharmaceutical, ranging from handwashing, use of PPE and facemasks, lockdown, environmental decontamination, administrative control to waste management, have stemmed community transmission and high mortality. The Case Fatality Rate for Kaduna State is 1.0% and relatively low compared to the national average of 2.2%.7,39 The state has tested 11,583 samples for COVID-19, and expectedly the incidence of COVID-19 has risen, but the majority of the confirmed cases presented with none to mild symptoms, and many made a full recovery after treatment.40
Challenges
The Kaduna State COVID-19 response has witnessed many challenges. The challenges range from disobedient and resistance from the public, scarcity of PPEs, lack of bed spaces, stock out of test kits and reagents, lack of funds and declining government revenue, hunger, and frustration to uncertainty.
Disobedience and resistance: the COVID-19 response has to contend with the low-risk perception of the public. The majority of citizens in the inner city do not believe COVID-19 existence and are least prepared to comply with the non-pharmaceutical measures and other guidelines laid out by the government.41 The politicization of the pandemic by government critics and those dissatisfied with the government of the day made risk communication a daunting task.42 The deployment of jingles in Radio and Television in English and Hausa informed and educated the citizens on the danger of COVID-19 and the expected behaviors by the government from all citizens to stem the spread of the virus.43 The enforcement of new and existing registration assisted in behavior change and compliance with approved measures and guidelines.44
Scarcity of PPE: The global demand for PPE made them expensive and difficult to procure.45 The government enforced rational use of PPE to limit abuse and waste, on the one hand, and to prioritize and maximize their use on the other hand. The health workers were instructed to recycle PPE that can be recycled and plan tasks to optimize the use of PPE.46 The government also solicited for and received PPE from donors within and outside the state.
Lack of bed spaces: the rising incidence of COVID019 cases has put pressure on the available bed spaces at the isolation and treatment centers, necessitating the management of some patients at home as the preferred option.47 Home management has its challenges, from adherence to instruction, the suitability of homes, logistics difficulties to the risk of secondary infection.48 The renovation and adaption of alternative isolation centers like Hamdala Motel,
Zaria hotel, and Kafanchan School of Nursing to an isolation and treatment center freed many rooms for patients’ isolation and treatment.
Stock out of test kits and reagents: the three approved laboratories (DNA Lab, ABUTH
Zaria, and mobile testing truck) daily battle with scarcity and shortage of test kits and reagents.49
The test kits and reagents are not readily available at the market, and lockdown and global restriction of the movement have made procurement very difficult. The government, through improvisation and support from NCDC, maintained daily requirement of commodities for the laboratories to function.50 The lack of funds and decline in government revenue: COVID-19 response is costly, threw up unexpected expenditure, and worse, government revenue has collapsed.51 The state government has to make an emergency appropriation and fund provided to renovate facilities for isolation and treatment, procure commodities and drugs, feed and cater for patients, remunerate health workers and overheads for transport and running of facilities. The government opened a dedicated account and has received donations from philanthropists and well-meaning citizens.
The government officials and civil servants contributed at least 25-50 % of their basic salary to the response.52
Hunger and frustration: the citizens are tired of staying idle, and the government has no provision of social palliative to satisfy all the citizens’ demands. The palliatives (food) provided by the government could not reach higher than 15% of the vulnerable groups, whose source of income has been truncated by the lockdown.53 The frustration occasioned by the lockdown was so palpable and tense that the government has to create windows for shopping and restocking of essentials and food two days every seven days. After 75 days of full lockdown, the government relaxed the lockdown to night to dawn curfew, 8 pm to 8 am.54
Uncertainty: the uncertainty of the pandemic has kept pupils and students away from schools, polytechnics, and universities.55,56 The markets remained shut, and only makeshift markets provided for the needs of the citizens. The civil servants are yet to resume work, and many businesses have not picked up after lockdown relaxation. No one is sure how the pandemic will eventually pan out and when we shall return to near normal. The cost of the pandemic remains huge from individuals, corporate, and government losses, and the recession will inevitably run deep on many levels.57
Conclusion
COVID-19 is real, has maimed citizens, and claimed many lives. The economic, social, and human losses are enormous, and recession stares us in the face. We have no cure or vaccines to deal with the pandemic yet, so prevention and adherence to proven measures by citizens, corporate organizations, and the government to stem the incidence of the virus must be accepted as the new way of living. The challenges are daunting, but consultation, cooperation, and communication among citizens, corporate organizations, and government remain essential to finding the strength, resolve, and shared purpose to cultivate useful guidelines and measures to keep individuals, organizations and government running. Conflict of Interest
The authors declare there is no conflict of interest.
Funding
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