COVID-19 has stretched Nigeria’s health system, economy — NCDC DG, Ihekweazu

The Director-General of Nigeria Centre for Disease Control, Dr Chikwe Ihekweazu, speaks with FRIDAY OLOKOR on the state of the health sector in Nigeria and efforts to end the spread of COVID-19 in the country

The number of those contracting coronavirus is dropping compared to when Nigeria was having 600 to 700 cases daily, yet the government says we have yet to reach the peak, how can you explain this?

It is still too early to decide that we have reached the peak of the COVID-19 outbreak in Nigeria. As we expand our testing capacity and reopen society, we may record an increase in cases. We are learning from countries in Europe and other parts of the world that a decline in new cases does not translate to being at the end of the pandemic. In most of these countries, they have begun to record an increase in cases again. In other cases, the virus has continued to spread but not exponentially. We will continue to strengthen our diagnostic, case management and other response capacities to be prepared in the event of a spike in cases.

Do you foresee a time in Nigeria and the rest of the world when there’ll be no single case?

The only disease in modern times that we have been able to reach eradication for and have no record of any case is smallpox. This was eradicated largely by global immunisation efforts. At the moment, we do not have an effective vaccine against COVID-19. Until then, we must adhere to public health and social measures such as physical distancing, using of face masks when in public settings, avoiding large gatherings, hand-washing, etc. Importantly, even when we have a vaccine, it should not be seen as the magic bullet. We have a vaccine for measles but continue to record thousands of cases every year. Therefore, our protection will not only depend on a vaccine but also on the behaviour of individuals.

We have yet to do sufficient tests, compared to other countries, what is responsible for this?

Prior to the COVID-19 outbreak, we had less than 15 molecular laboratories across the country, unlike many other countries. We had to start from close to ground zero to build up. In addition, the most commonly validated technique to test for the virus that causes COVID-19 is the PCR (Polymerase Chain Reaction) method, which is expensive to establish and requires intensive molecular training. So, we had a slow start, but we have now increased our pace. We have activated 63 laboratories across 30 states and the Federal Capital Territory. We are supporting the remaining states to establish laboratories by the end of September 2020.

We are also working with states to establish sample collection centres to increase access to testing. In some states, we are leveraging risk communications to increase demand for testing. There are various reasons why we have not tested as much as we should, but the improvement of our testing rate remains a major priority for the public health response.

How many tests would we need to do before we can say we have done enough, or do we need to test all Nigerians?

There is no exact number to aim for, but we have a guiding principle. WHO recommends that the percentage of people who test positive should be 10 per cent or less. If there is a high percentage of positive cases, it points to ongoing community transmission and insufficient testing. At the moment, our positivity rate is 13.9 per cent. We do not need to test all Nigerians as it will amount to a waste of limited resources. However, we will continue to test those who meet the case definition, including close contacts of infected persons. The more we test, the better we can establish the true burden of COVID-19 in Nigeria.

At the moment, how much does the unit test cost the government?

Maintaining our laboratory capacity is one of the costliest aspects of the response. In addition to the reagents and extraction kits, samples are collected using virus transport media paid for by the government, and transported through a courier system funded by the government. The public health laboratories also fund their staff, provide 24-7 electricity, water supply and other utilities.

Violation of safety protocols at burials is one of the major violations that we have had and it has happened over and over again, does it mean we can’t help this?

Ultimately, the control of this outbreak relies largely on the behavior of individuals. At NCDC, our role is to provide the necessary guidelines and public health advice. We have done this by publishing and widely disseminating guidelines on safe burials during COVID-19. This is available on www.covid19.ncdc.gov.ng. While we recognise that burials are an intimate part of our society, we have to make sacrifices at this time. The use of law enforcement for public health is not usually the preferred option. We will continue to strengthen our risk communications and community engagement processes to ensure that Nigerians are not only aware of the risks, but also adhere to public health guidance.

There have also been political campaigns going on in Edo State where there has been zero observance to protocols, what do you think about this?

Prior to the start of political campaigns in some states across the country, we developed a guideline for conducting elections safely in the context of COVID-19. This is an unusual occurrence where we have elections in the midst of a pandemic. We know that the virus that causes COVID-19 is more likely to spread in public gatherings. It is very important that we all adhere to these guidelines. Apart from the direct effect of COVID-19 on those who are infected, our health system and economy are stretched. There are ripple effects from not adhering to guidelines that we can and should avoid.

Some people have said the number of persons discharged in recent days have been high, making them to feel it’s not as bad as presented, why is this so?

We must recognise firstly, that science is not fixed but evolves. This is what underpins public health. As we generate and have access to additional evidence on the pandemic, we will adjust our response accordingly. We recently provided additional guidance to states on recording discharge of cases that never presented to any treatment centre and were managed at home. Previously, we were recording only cases discharged from treatment centres. This means that we did not have a true representation of active cases in states.

We have rectified this by providing the relevant guidance. While our data collection process is not perfect, we have worked very hard to improve this process. We have teams working 24-7 to review data that come in and verify them before we publish to the public. We are fully committed to transparency in reporting to the public. This is why we have published a situation report every single day and not missed any day since February 27, 2020.

What percentage of our cases is severe and what the percentage is mild?

The majority of the cases we have recorded are mild, as most people who have been infected are between the ages of 31 and 40. This is similar to global statistics as there are more mild cases than severe cases.

What is the situation of things now in Kogi and Cross River states, whose governments said they had no case of COVID-19?

We are working very closely with the governments of Kogi and Cross River to support response activities. We have deployed Rapid Response Teams that are supporting the states to strengthen their emergency response capacity, including early case identification, contact tracing, risk communications, etc. We have supported both states to activate laboratories for testing and will focus on increasing access to testing in the coming weeks. We are grateful for the efforts of the ministries of health in both states and remain committed to supporting their response. It is only by testing that we can establish the true burden of COVID-19.

In terms of compliance with safety guidelines, how would you rate the overall compliance by Nigerians?

Our response is largely guided by data. We have monitored the use of face masks, physical distancing and other measures among Nigerians. We can definitely do better with adhering to these. The reopening of our society does not mean the virus is no longer with us. It means we have to learn to continue with our lives safely. This will require sacrifices in some areas, but it is worth it. If we comply with the measures in place, we will reduce the risk of transmission of COVID-19 in Nigeria.

From the much you’ve seen, what do we need to do differently in the immediate future?

We all need to take responsibility. The response is not for the government alone. If you must go out, please wear a face mask properly and keep it on. If you own a business, please provide hand-washing facilities and other requirements for your staff members to be safe. Our religious centres need to ensure that attendees adhere to the public health measures in place. Our safety depends on personal and collective responsibility.

The Federal Government appropriated in the 2020 Amendment Act the provision and purchase of molecular laboratories equipment over 55 teaching hospitals and federal hospitals nationwide to tackle the pandemic. What is the update with the purchase?

The government of Nigeria is increasing investment in health security which is one of our biggest needs. These laboratories are not just to serve the current need, but also for future outbreaks. We have begun the process to improve the current capacity in laboratories across the country so that we are better prepared for the next outbreak.

How have continual strike actions by health workers over the issue of allowances affected the centre’s activities and the overall fight against the pandemic?

Since the beginning of the pandemic, health systems in countries across the world have been overstretched. Health workers have been at the front line to provide care to patients and maintain routine health services. We need more health workers in the fight, and not less. While our mandate as it relates to case management is limited to providing guidance and support to states and treatment centres, the reduction in the number of health workers available can affect the timeliness and quality of care provided to COVID-19 patients.

A lot of persons have said that it seems Nigeria didn’t learn its lessons from the 2014 Ebola outbreak as our health system is still in a mess and ill-equipped amid the COVID-19 pandemic. How do you react to this?

In the last four years, we have focused on strengthening our health security infrastructure in Nigeria albeit with limited resources. One clear difference between the 2014 Ebola outbreak and COVID-19 is that our country now has the capacity to test and confirm the virus locally, without being dependent on other countries. This is coordinated at the centre by the NCDC National Reference Laboratory, a facility which was operationalised only in 2017. The NRL is now the single largest public health laboratory in Nigeria, with our team working 24-7 and providing services to all states in Nigeria.

The first few laboratories that could test for COVID-19 in Nigeria in addition to the NRL, are those that we have supported in the last four years to test for other viral diseases, especially Lassa fever. In April 2017, we began a huge task to support every state in Nigeria with its own Public Health Emergency Operations Centre. As at December 2019, we were in 24 states already. These EOCs have been the hub of coordinating response activities at state level. We have also supported various infection prevention control training programmes for health workers that provided a foundation at the beginning of the COVID-19 outbreak. The COVID-19 pandemic is an unprecedented one – one that has stretched health systems across the world. While we were not where we would prefer to be, we have made significant progress between the Ebola outbreak in 2014 and now. The biggest priority for us now is to increase and sustain current investments in our health security so that we are better prepared for the next pandemic.

The insufficiency of personal protection equipment and the many hazards faced daily by health workers as against the humongous budgets earmarked for the centre, health ministry and other donations internally and externally do not seem to match. Why are we having shortages despite the huge allocations?

Despite the global shortage of PPE as a result of increased demand, we have worked very hard to ensure that health workers are provided with the PPE required to protect themselves. This has also been supported by our partners. We continue to improve our logistics system to avoid these shortages and ensure health workers are empowered.

Do you think the government has encouraged local initiatives well enough to tackle this pandemic? For instance, it was silent for too long on the Madagascar drug and later came out to disprove it, whereas we haven’t brought out analysis of our own locally manufactured products.

The development of vaccines, drugs and other pharmaceuticals is a long and strenuous process that requires great attention to details. And it requires huge investments. It is very difficult to start this from scratch in the midst of a pandemic. We are fully committed to supporting local initiatives that meet safety and other related requirements. This has been emphasised by the Directors General of the National Agency for Food and Drug Administration and Control and the Nigerian Institute of Pharmaceutical Research and Development, whose agencies have the mandate for drug development. We will continue to support validated scientific outputs led on and carried out by Nigerians.