Rethinking our Response to COVID-19: Learning from Ebola, Spanish Flu and MERS

Abstract:

Disease outbreaks impact human lives negatively in different facets. To curtail the extent of such devastation, it is imperative to design, implement and monitor interventions that can contain the outbreak with minimal impact. With the outbreak of coronavirus disease (COVID-19) in Wuhan China in December 2019, the spread have been rapid with massive distress to the world.

Spanish flu, Ebola virus disease (EVD), Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) are some disease outbreaks that have been witnessed with almost similar havoc caused. In efforts to respond to this current outbreak, we should learn from past experiences, adopt good practices that worked and improve on these for a speedy recovery.

This paper draws on experiences from Spanish Flu (1918 – 1919), Ebola in West Africa (2014 – 2016) and anecdotal correlations from MERS and SARS to outline approaches that can help flatten the curve of transmission, improve care for COVID-19 patients and build resilience in healthcare systems.

Key words: Disease outbreak, Transmission, Health workers, Community mobilization, Health communication.

Background:

Disease outbreaks have been with us from time immemorial and over time our response has always been better than before. The most devastating disease outbreak that hit the world by storm was in 1918-1919 post-World War I, Spanish Flu. It is reported that over 500million people were affected accounting for about one third of the world population[1] with a death toll of up to 50million[2].

The current fatality rate of coronavirus disease (COVID-19) is at 2.2% which is lower compared to other respiratory disease outbreaks which caused havoc in the world e.g. SARS and MERS with a fatality rates of 10% and 35% respectively. Compared to these other viruses its spread is so rapid and this may be the greatest challenge in dealing with it and probably cause for substantial mortality figures when it is contained[3].

The World Health Organization (WHO) have called on governments, private sector and the general public to join forces to flatten the curve of transmission. This is through adoption of hand hygiene measures, social distancing, using face masks, self-isolation, not touching faces, avoiding social events and public gatherings, and seeking care when presenting with symptoms. Several countries have adopted these measures and went an extra mile to enforce curfews and lock downs to reduce human movement and with it spread of the disease. Travels have been brought to a halt both local and international. These are great measures and if done the right way and scaled to the last mile we hope the impact will not be as severe compared to if not complied with.

Wisdom is learning from past experiences to chart a course of action to realize favorable outcomes in the end. Considering COVID-19, is not the first outbreak we are witnessing we should learn from the previous experiences and design our interventions thoughtfully.

Spanish Flu: 1918 – 1919

In the wake of Spanish Flu which is suspected to have originated from China but because of media freedom in Spain, was first reported there, there were myths and misconceptions around this. These were worsened by health systems shortfalls as most doctors had been killed during the world war.

There were claims that the flu was an outcome of the terrible Spanish weather and therefore Britain’s wet climate might stop the spread there as reported by The Times, a British Press. These are linked to the current claims we are having with COVID-19 where due to low count of infected people, there were claims on African weather conferring some protection against the virus.

Capitalism played its fair share with a vitamin company advertising its vitamin product (Formamite) as a best means to prevent the infection process. This was made to look like a public notice on the symptoms of the virus in the British Press. The negative impacts of this have not been reported. This same situation is being witnessed with COVID-19 where companies are sponsoring adverts in media to educate the public with claims on efficacy of their products against coronavirus. The most conspicuous have been those for antiseptic soap companies which sell antibacterial liquids with no known activity against viruses e.g. Dettol liquid constituted of Chloroxylenol with label claims of activity against viruses. Same applies to the production of hand sanitizers and cloth face masks by unscrupulous dealers to rake in profits while offering the public substandard products which doesn’t only provide a false sense of protection but also increase risk of spread.

Due to health worker shortages, medical students were recruited to offer help at times of crisis. This has been witnessed in some countries with COVID-19[4][5] but unfortunately in some developing countries we have unemployed health workers[6] who can be mobilized into service to provide care to patients at this point in time. It’s imperative that governments in these countries leverage on this advantage to maximize on this local capacity.

Ebola: 2014 – 2016 (West Africa: Guinea, Sierra Leone and Liberia)

Ebola outbreak caused devastation in West Africa causing up to 12,000 deaths. It was estimated that the impact of the outbreak on health systems was severe with more deaths from diseases other than Ebola over the same period[7]. Respondents adopted innovative ways to reduce spread and mitigate the impact including elbow-knock instead of shaking hands, appointment of single caregiver in a household to look after the sick, safe & respectful burials. These were coordinated in collaboration with the local authorities which made it easier to have the information contextualized for use by the communities. Information about COVID-19 is fast changing and this is coupled with guidelines from WHO meant to be adopted by national authorities and stakeholders to support in response to the outbreak. For this information to drive impact, there is need for it to be contextualized and shared with local communities in a manner that they understand and can apply to their lives.

It was also noted that communication was majorly one-way which impeded collection of feedback from the community about what could be done better. This is a feature we can integrate in our responses especially considering the impacts of this outbreak are far-arching with need for alternative approaches to respond in these diverse ways. In areas where the COVID-19 infections were first detected just like with Ebola fear and stigmatization has crippled this societies impairing the health seeking behaviors of the symptomatic persons. Effective communication of the real facts of disease progression in the community and uncertainties on the same by the governments is necessary to manage the panic and put trust in the health system. Information on preventive measures should also be precise and clear to ensure the key points are not lost or diluted.

Spread of Ebola was majorly through body fluids which made the numbers be manageable yet there was a strain on the healthcare systems. With COVID-19, transmission is through air and bodily contact that making case numbers to be likely to be much higher. This will put extra strain on health systems especially with need for specialized ICU facilities. It will also cause death from other disease through this impact on the health system. To better respond, there should be designated COVID-19 management centers with other health facilities clearly communicated to the public as centers where they can continue accessing other health services. This can be adopted from the concept of Ebola Treatment Centers (ETC) with a feature of Community Care Centers (CCC) that integrated the local community in the activities for social acceptability. It was reported that the CCC helped change the relationship between families and responders from fear to active cooperation which is very important at this point [7].

With the closure of Kenyan borders and the last flights of quarantined persons coming into the country coupled with continued increase in reported cases, it’s evident that the disease has found its way to the rural communities. The preparations and prevention measures taken up by the local and national governments are commendable. However, the spread of the virus is potentially deep to the grassroots levels especially in densely populated areas as evidenced in the Ebola outbreak in rural Congo. This will definitely overwhelm the existing healthcare system thus need to involve community health workers (CHWs) and leaders in rural/ hard to reach settings. The approach was applied in Liberia through basic education of the community leaders with “low-hanging fruits” like the rest of the community thus were not able to make significant impact as first responders. This emphasizes the need to equip CHWs with all essential information backed by facts to optimize their impact[8]. Community driven self-quarantine and self-isolation based on understanding of the benefits was critical in Ebola control. Community youth were mobilized to help identify infiltrators, enforce self-isolation and protective sequestration. This helped in controlling spread within the communities [7].

Prompt case finding, diagnosis, treatment, contact tracing and quarantine are key measures to eliminate new foci of transmission. These are dependent on diagnostic capacity which is based on availability of test kits, proper transport measures for transfer to hospitals/isolation centers for those suspected or contacts. This calls for good governance in terms of operational coordination[9]. In the Ebola outbreak, Médicins sans Frontières (MSF) deployed its humanitarian framework to help address the shortfalls[10].

To effectively respond to and mitigate the impacts of COVID-19, there is need to adopt broad-based one-health approach, effective two-way communication, community mobilization and health systems strengthening with mutual value for all stakeholders. It’s through such structured approach that we can attack the outbreak from different angles and arrest its spread and devastation before we are at its mercy.

Finally, one of the major causes of deaths in the world with or without pandemics is preventable errors. The array of complications arising from COVID-19 infections ranging from heart failure, acute kidney failure to pneumonia among others are a pointer that extra care should be taken in management of these patients. Additionally, adverse events are prone to happen as a result of compassionate repurposing of different drugs e.g. hydroxychloroquine, lopinavir/ritonavir etc. There should be documentation of these interventions and any anomalies noticed in care of these patients as this will form basis for improving the treatment guidelines. In comorbid patients, detailed disease and drug history should be taken to avoid probable adverse effects e.g. use of hydroxychloroquine with drugs with a propensity to impair respiration e.g. antipsychotics. As part of internal improvement measures, refresher trainings infection prevention and control and common respiratory complications should be adopted for healthcare providers (HCPs).

Recommendations:

1. Communication

  • Precise and concise details to be relayed at any one time.

  • Information being relayed to be an accurate account of the prevailing situation to build confidence in the system

  • Communication be timely and easy to understand

  • Communication medium should allow for two-way transfer of information to collate feedback and improve systems

  • Communication to be matched with good parallel operational services

2. Healthcare Providers (HCPs)

  • Be supplemented in numbers i.e. employ more HCPs

  • Be provided with sufficient quantities of PPEs of the right quality standards

  • Be classified as high, intermediate and low risk groups depending on extent of contact with patients and be segregated accordingly to limit risk of infection & transmission of disease from HCPs.

  • Be regularly updated on new findings and emerging protocols anchored on scientific evidence for better treatment outcomes.

  • Be provided with simple standard operating procedures (SOPs) for specific operations to reduce chance of error especially under the strenuous conditions.

3. Preventable Errors

  • All interventions to be documented at every stage of care.

  • Patient prognosis to be monitored and any changes documented.

  • Clinical complications identified to be reported and corrective and preventive measures be instituted on a timely manner.

  • Probable adverse events e.g. drug-drug interactions, adverse drug reactions and drug-disease interactions to be marked on high alert.

  • Patient stratification based on severity of disease and patient risk group e.g. pregnant women to be put on close monitoring for any unexpected complications.

4. Community Based Interventions

  • Community health workers (CHWs) to be well trained & equipped with the essentials to enable them serve as first line of response.

  • Community leaders, informal leaders and local influencers be involved in design and deployment of community interventions.

References

[1] The Effects of the 1918–1919 Influenza Pandemic on Infant and Child Health in Derbyshire: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1088249/ [2] Spanish flu: The deadliest pandemic in history: https://www.livescience.com/spanish-flu.html [3] 3 charts that compare coronavirus to previous outbreaks: https://www.weforum.org/agenda/2020/02/comparing-outbreaks-coronavirus-mers-sars-health-epidemic [4] Medical students join the fight against COVID-19: http://sites.middlebury.edu/cci/health-professions/the-news/medical-students-join-the-fight-against-covid-19/ [5] Greek Medical Students Enlisted to Help with COVID-19 Patients at Sotiria Hospital: https://www.thenationalherald.com/297968/greek-medical-students-enlisted-to-help-with-covid-19-patients-at-sotiria-hospital/ [6] KMPDU MEMORANDUM TO THE SENATE AD HOC COMMITTEE ON COVID-19: http://kmpdu.org/download/kmpdu-memorandum-to-the-senate-ad-hoc-committee-on-covid-19/ [7] What Might Africa Teach the World? Covid-19 and Ebola Virus Disease Compared: https://africanarguments.org/2020/03/17/what-might-africa-teach-the-world-covid-19-and-ebola-virus-disease-compared/ [8] Development of a set of community-informed Ebola messages for Sierra Leone: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005742 [9] How to manage in a crisis: lessons from the West Africa Ebola outbreak: https://theconversation.com/how-to-manage-in-a-crisis-lessons-from-the-west-africa-ebola-outbreak-121590 [10] A humanitarian response to the West African Ebola virus disease outbreak: https://link.springer.com/article/10.1186/s41018-018-0039-2

Authors: Ms. Lilian Muthoni and Dr. Odhiambo David