April 19, 2020

How community transmission is fueling virus – Dr Doyin Odubanjo

How community transmission is fueling virus – Dr Doyin Odubanjo

What is local transmission and community transmission?

Local transmission means that the virus is transmitted (from person to person) a country and not that someone who had travelled came in with the virus. It means that you have cases of people who got it from imported cases, like contacts of the index case (the Italian).

After that, if somebody who never travelled catches it from somebody within the country, or people are passing it to one another within the country, that is local transmission.

Another characteristic of local transmission is that you can fairly easily tell the story of how the person got the infection. You can tell how it happened but when you start getting to the place where the picture is not that clear, that is when you talk about community transmission. Where people have caught the infection and you are finding it almost impossible to trace where they got it from, you have reached community transmission phase. At this point, the detective work has become difficult and you can no longer link it to another person easily.

What are the implications of community transmission?

When you get into community transmission, you can no longer track who is who. At the end of the day, the tendency to get into community transmission is largely because many people, who have no symptoms, will spread it without knowing. What you expect in a community spread is that, if adequate steps are not taken, you will get an exponential rise in cases because you are having cases you cannot isolate and test.

There are people who are not under your radar at all. You are not looking for them because you did not even know about them in the first place. Your only hope is that they never catch the disease. But that is also why Lagos State government has told us they are running a door-to-door case detection. This means that they go into the communities and they simply ask the various houses if there is anybody there with relevant symptoms such as cough and fever.

The commissioner said they had 119 people with such symptoms and that is why they have to do that. I don’t think we have everybody listed as a contact, that is why they have to start looking for people everywhere. It may be that the cases will rise exponentially but it looks like the cases here will be a little different from what we are seeing in Europe.

We are grateful for that because it looks different in a good way and may not be as severe. However, right now, we are not pretty sure of what is going on. The best bet is to search everywhere possible for cases and this is becoming very difficult to do with increasing spread across the country. That is why I guess there was an extension of the lockdown to catch more people in their houses.

Now that we have community transmission, what should government be doing?

The Nigerian Academy of Science (NAS) had, in a press statement issued days before the lockdown, (titled, ‘Time to lockdown’), called for a national lockdown with national guidelines. NAS called for a lockdown then because it was suddenly found that the seemingly controlled situation was not as controlled and the disease was found to have reached an unexpected level and had even attacked the highest echelons of government. At that time, governors tested positive, even the Chief of Staff to the President and others got infected with the virus. A few weeks ago, there was panic everywhere because the virus caught everybody by surprise.

But NAS expected a national lockdown with national guidelines. This means there should be proper national coordination of a national lockdown. First, you keep everybody where they are to investigate the real situation in terms of spread (while also limiting spread), but you must have worked out, very meticulously, the guidelines to do that because of the social-economic challenges and see how to do it without killing people with hunger. The idea behind the NAS’ four weeks recommendation was to have enough time for you to be able to find all the cases that existed. If anybody will show symptoms, most should show it by then.

If we had done it that way, we would easily then come out with a clear picture of where we are. More people with the symptoms would have called in or be found. And because you cannot continue a lockdown for too long, you can also work out a good plan for an exit from the lockdown so that our economy can continue and you don’t leave people in hunger. We must look into what we can do that will be practical and effective in the country.

After the lockdown, one of our problems will be drugs. We don’t manufacture the various drugs that people will need. We must know that people will be dying even from other things because they cannot get drugs or access to health care. So the lockdown was good to quickly control a chaotic situation but you have to know that it must not continue like that.

At this time, what government needs to do is to put in a lot more effort into community engagement and education, get people to really know what this is all about, from the lowest to the highest level. Even some people, who are under lockdown now, don’t really know why they are locked down. Many people in the slums under the lockdown don’t understand why they are told to stay at home instead of going about their daily businesses.

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We need to take this time to do community engagement and education and get people to understand that while it may not look all that bad, this is what the condition looks like and only a few people will come down with severe disease and may even die. But if those people were your own relatives, you don’t want them to die. So you have to explain to people and approach them properly.

If you are quoting to them how many people died globally, of course, they have not seen the people dying there, so they can still dissociate from it. The truth is that it is not going to be testing alone that will control the disease for you. Practically speaking, you need to test but you are not likely to find every single person with the disease. The most effective tool you have is community support and community awareness. When people understand, they will behave the right way in order to limit the spread of the disease. Not only that, the community will then be active participants in disease surveillance and find cases for you.

Secondly, state governors and the Federal Government need to sit down now and work out a clear and exit strategy for lockdown and closure of borders. So what are we going to do to get back to ‘normal’? Even government cannot sustain palliatives. As soon as we reopen our borders and there are still cases anywhere in the world, there will be a risk of importation of new cases. We need a practical and effective strategy, one way or the other; we need to have plans for dealing with cases whether it is community transmission or imported cases when we open the borders again. It is time to work out a detailed, practical, and effective strategy. We need to involve a multidisciplinary team led by experts. I see a lot of politicians in what we have been doing and we need to see more experts too.

Is it necessary to extend the lockdown nationwide?

It is now quite complicated because it was probably better to do it uniformly. When the lockdown started three weeks ago, there were about five or six states with confirmed COVID-19 cases. Right now, there are about 20 states. Right now, there is nothing that assures us that the disease is not spreading in other states.

Now, there is community transmission; when you remove lockdown in Lagos, what says that some people in those states will not bring it back to Lagos? So, it would have been better if things were done in a coordinated way. Already you have a problem even between Lagos and Ogun States. Remember, Ogun negotiated to start on a Friday (four days later) instead of Monday night. So what exactly does extension mean for Ogun? Is it another 14 or 21 days?

Those are the complications that should have been avoided. We should just have assumed that we don’t know where the cases were in the country and we wanted a little time to keep everybody immobile, as little as possible, so that we can find the cases and know where they are and what the situation really is in the country.

For instance, while we were on lockdown, we found a case in Kaduna which supposedly came from Lagos. We found a case in Daura which supposedly came from Lagos. A uniform thing would have been better and, even up till now, we have governors coming up with different rules. All that will not help us contain the spread of the virus.

Whatever we do, we need a lot of collaboration and more talking together among the governors and the Federal Government so that things are done with some degree of uniformity. That is our best bet especially given the level of our illiteracy and poverty. We need a unique coordinated approach that will be most effective. It does not mean that your rules will be exactly the same thing, but it means that they will all agree to the rules and know exactly why we are making them.