Introduction
An Influenza pandemic in 1918 could be considered to be the most fatal event in human chronicle constituting about 50 million and more deaths, which could be equated to in magnitude of 200 million in the global population today. For more than a century, it has stood as a benchmark against which all other pandemics and disease emergencies have been measured. As scientists across the globe remember the 1918 pandemic, there is another global pandemic and infectious-disease – novel coronavirus infectious disease (Covid-19) caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) reported in December 2019 by Health Authorities in Wuhan, Hubei Province, China. This could be considered as the first modern pandemic even though speculations thought Ebola outbreak in West Africa could qualify as such.
This pandemic has summoned all of humanity against the virus. Its negative effect on humanity videlicet health, wealth, businesses and well-being is already enormous. This is synonymous to a world war except in this case it is not humanity against humanity but humanity on one side against an invisible virus.
In the early stages of Covid-19 infection, most patients presented with symptoms of fever, dry cough and shortness of breath that may rapidly result in severe respiratory distress syndrome, respiratory failure, multi-organ failure and death. Among cases reported in Iran and U.K, the dailymail has reported that patients have newer symptoms such as fatigue, insomnia and loss of smell with a complete absence of fever though 70% of cases could present symptoms described by the World Health Organization.
A research finding of COVID-19 among 408 homeless people in Boston shows a 36% positivity rate and 87.8% asymptomatic carriers. These results suggest that symptom screening may not adequately capture the extent of the disease transmission in high-risk settings.
The World Health Organization (WHO) Notified
The WHO, an organization established 72 years ago with the mandate to direct and coordinate issues of international health within the United Nations System was notified of a rapidly spreading pneumonia of unknown origin on January 7th, 2020 by the Chinese Health Authority. The organization has since been working with all partners by advising member countries on measures to contain the virus and treat infected people among other things.
By the end of January, the virus had been exported to several countries in Europe and rapidly spreading pressing on the World Health Organization (WHO) to declare the outbreak as a Public Health Emergency of International Concern on 30 January 2020, guided by the International Health Regulations (2005).
The Virus: SARS-Cov-2
The novel coronavirus currently in circulation is a member of the family Coronaviridae. Until the discovery of this novel coronavirus, six coronaviruses are known to infect humans; the alpha coronaviruses 229E and NL63 and the beta coronaviruses OC43, HKU1, SARS-CoV, and MERS-CoV.
All known coronaviruses were isolated from animals and infect animals than humans with some infecting more than one different species of animals.
The new coronavirus SARS-Cov-2 like other members of the family is enveloped with unsegmented single-stranded positive-sense RNA with a pleomorphic (appearing in different forms) and circular structure measuring about 60-140 nm in diameter.
According to the Chinese scientists, the whole sequenced genome SARS-Cov-2 showed 96.2% similarity to SARS-related coronavirus and <80% similarity to SARS-CoV isolated from bats in China. Scientists from the University of Ghana have also sequenced the genome of SARS-Cov-2 circulating in Ghana as a way to strengthen their surveillance effort. All 15 genomes as asserted by the University of Ghana in greater extents resembled (with > 92% similarity) the reference strain that was isolated in Wuhan, China. Signifying the viral strain has not significantly changed as the country is battling with the same pathogen which the rest of the world is battling against.
However, recent reports have indicated some mutations in the circulating virus in different regions. It is important to note that mutations are common by-products of viral replication and does not exactly confirm a change in function and biology of the virus. Mutations that eventually result in new strains of viruses can produce a more virulent virus that is capable of out-witting drugs and
vaccines being developed or may also result in a virus that is less virulent compared with the original strain. Research is currently ongoing to ascertain whether or not the mutations been reported has resulted in a change in function and/or the biology of the circulating SARS-Cov-2 and hence different strains.
Scientist at Senegal’s Institute de Pasteur had also shown some sense of urgency by developing a simple test kit that is cost-effective to test for the infection. Other Pharmaceutical agencies in Ghana in partnership with the Kumasi Center for Collaborative Research (KCCR) had also developed a rapid diagnostic test kit yet to be certified by the country’s Food and Drug Authority (FDA).
The virus is believed to have jumped species from animals to humans and now been transmitted between humans through respiratory droplets from coughing, sneezing, spitting and aerosol-generating procedures by clinicians. Scientists including public/Global health professionals believe the virus might have had an intermediary host before jumping onto humans. With an incubation period of 7 to 14 days, asymptomatic carriers are reported to be the major source of transmission.
The Statistics
As of August 8, 2020, 213 countries around the world and 2 international conveyances have been affected by the virus with a cumulative reported confirmed cases of 18, 379,913 resulting in 11, 590,880 recoveries and 695, 311 deaths. As a pandemic, Ghana is also affected with an estimated 37,312 cases, 34,313 recoveries and 191 deaths as of August 8, 2020. Death rates are highest among people aged 70 and above; and people with underlying diseases such as diabetes, hypertension and asthma.
The Frontline Health worker
Research shows that frontline health workers have three (3) fold rise in the risk for covid-19 as a result of their proximity to confirmed, suspected or patient with covid-19 but has not met the criteria for suspected covid-19.
Reports from Wuhan, China where a large cluster of infections among health workers occurred is an example of how frontline health workers have increased risk of covid-19.
With over 1.4 million health workers infected by SARS-Cov-2 globally in their line of duty, representing about 10% of the global cases, the supply of essential Personal Protective Equipment (PPE) remains a global challenge.
In Ghana, over 2,000 health workers have been infected with the virus resulting in more than 16 deaths by 9th of July, 2020. The various professional bodies within the health sector workforce have indicated time and again how their members lacked the essential PPE needed to protect their members while taking care of Covid-19 and potentially Covid-19 patients. It appears there is more to be done by the government to overcome the challenges if the local war against covid-19 must be won.
The government of Ghana as a way of motivating frontline Health workers who place their lives on the line for the good of the Ghanaian public introduced income tax waivers and other financial incentives including insurance package for frontline health workers.
Africa and the Ghana Perspective
The African region experiences around 100 public health events annually, of which 80% are caused by infectious diseases. Although only a portion of these public health events are caused by emerging and dangerous pathogens (EDP), recurring outbreaks of diseases such as Ebola Virus Disease (EVD) and Dengue Fever is a feature of the regional situation and in recent times the global outbreak of SARS-CoV-2 could not be ruled out. The health impact of COVID-19 probably differs in African settings as compared to countries in Europe or Asia. This may be due to demographic, epidemiological, environmental, socio-economic and behavioral differences. West African countries especially Guinea, DR Congo, Sierra Leon and Liberia having dealt with 2014/2015 deadly Ebola pandemic in the region have been faced again with the challenges of SARS-CoV-2.
Using the global parameters as a benchmark, cases in Africa is generally low, however, the continent continues to record cases daily causing a rise in daily cases especially in West African countries. This contradicted earlier claims that the coronavirus may not likely be able to survive in West Africa due to the tropical climate in the regions.
Notwithstanding fatality rate is at its low side compared to temperate regions like Europe.
As a continent which has been implicated in many research findings as least prepared to manage pandemic and other health emergencies, African Union member states under the guidance of the
Africa Centers for Disease Control and Prevention (Africa CDC) have strengthened testing capacities in over 30 African countries including genome sequencing to understand the virus-specific strain in each country. Most countries in West Africa like many others in Europe and America has deployed at the beginning of the pandemic preventive measures as a way of curbing the disease through social distancing. The measures which are mostly banning social gatherings of all forms, closure of schools, some markets excluding those in food supply chain and border closures.
By the beginning of May, the Africa CDC had reported that, on physical distancing measures, 43 Africa countries had implemented full border closure and among these some allows cargo, freight and emergency entry/exit while others allow residents/citizens, but borders are imperatively closed, 7 countries issued international air traffic closures, 2 implemented travel restrictions to and from specific countries and 3 installed entry/exit restrictions. In light of this, all 54 member states of the African Union instituted mandatory quarantine for all travelers and/ or travelers from high-risk countries and have instituted a banned on all public gatherings, 53 member states have closed down all its school, 19 has placed limits on prisons and hospital visitations, 15 engaged in mass screening and testing and has initiated and encouraged public use of face mask. On the restriction of movement, 32 countries had implemented night-time curfews thus a restriction during a period in the affected area or nationally with 10 implementing curfews only and 22 included lock-down additionally to curfews. 19 countries instituted a partial lock-down comprising restriction of non-essential movement within an area in the country or region and 18 had initiated national lock with restriction of non-essential movement in the country.
Shielding (Physical isolation in a dedicated building) of high-risk individuals can reduce health service demand and, even more markedly, mortality if it features high uptake and low contact of shielded and unshielded people, with no increase in contact among shielded people.
The center continues to note that, strategies combining self-isolation, moderate physical distancing and shielding will probably achieve substantial reductions in mortality in African countries. Temporary lock-downs (which delayed epidemics by about 3 months), where socio-economically acceptable, can help gain a crucial time for planning and expanding health service capacity and infrastructure. This approach was taken by most countries and in Africa lasting not more than 30days in most cases perhaps due to the peculiarity of its member states and their economies.
In response to the SARS-CoV-2 epidemic, The Africa CDC has established the Africa Task Force for Novel Coronavirus (AFCOR). The Task Force is known to have made up of five working groups which are; disease surveillance, including a screening at points of entry; infection prevention and control in healthcare facilities; clinical management of persons with severe 2019-nCoV infection; laboratory diagnosis and subtyping; and risk communication and community engagement. The group included representatives of Member States, WHO, and other subject matter experts and partners. In Ghana, as measures have been put in place, Government intended to achieve five (5) key objectives and that is;
- Limit and stop the importation of the virus;
- Contain its spread; provide adequate care for the sick;
- Limit the impact of the virus on social and economic life;
- And inspire the expansion of our domestic capability and deepen our self-reliance.
Like most African Countries, Ghana also implemented preventive measures seeking to enforce social distancing but had to lift some of this restriction following a public outcry as a result of the socio-economic effect of the restriction. At present, Ghana has imposed compulsory use of facemasks within public space and strict observation of social distancing during all forms of public gathering. Schools remain closed except for final year students in Senior High Schools and the Tertiary institutions. Although since independence, Ghana does not have a specialized infectious disease management and treatment center, in the wake of this SARS-CoV-2 pandemic, the testing has been spearheaded by the Noguchi Memorial Institute for Medical Research
(NMIMR), a WHO Emerging and Dangerous Pathogens Laboratory Network (EDPLN) member reference laboratory of the University of Ghana.
To inspire the expansion of the domestic capability and deepen self-reliance, the country has engaged in a local production of Personal Protective Equipment (PPE) i.e. face shield and masks, alcohol-based hand sanitizers, gloves, clinical scrubs, boots etc. hitherto these were products largely imported.
Some members of the Ghanaian population seem to have been defying social distancing rules because they do not believe in the existence of the disease while others believe God is in control although there are others whose socio-economic situations makes adherence to such social distancing rule very much impossible, to say the least.
Immunity, treatment and vaccines
No group of people has demonstrated immunity against SARS-Cov-2 even though data available shows high fatalities among victims aged > 60years and people with serious underlying health conditions with no fatality recorded among children under 10. The increased risks of death among the aged have been attributed to reduced immunity to infectious diseases due to ageing and co-morbidities.
Nonetheless, whether people develop immunity to SARS-CoV-2 after being infected remain a challenging question for Global/Public health experts, policymakers and everyone affected by the spread of the Covid-19 pandemic.
A study in macaques provides a hint about such a phenomenon.
According to a Bao et al (2020), published by the scientist three Rhesus monkeys did not develop a second infection after recovering from the first exposure of SARS-CoV-2 virus and re-exposed to the coronavirus, alluding that primates are capable of developing at least short-term immunity to the virus. On the other hand, the research is not clear how long the protection lasts and whether the antibody surge the researchers observed is part of the initial stage when antibody levels are still dropping off, rather than a true memory response.
Despite this immune outcome, it still raises the question of why some Covid-19 survivors recovering and being discharged upon testing negative for the virus, only to then develop another infection. In perspective, this anomaly could be a result of suspected false-negative Polymerase Chain Reaction (PCR) testing or otherwise, this remains one of the numerous questions that need an answer.
Pregnancy makes the pregnant woman vulnerable to many infections and increases their risk for respiratory infections and pneumonia. Researchers in China found that pregnant women with Covid-19 in their third trimester are more at risk for severe respiratory symptoms requiring ICU care compared with the general population. Researchers have ruled out the possibility of transplacental infection as babies born to infected mothers tested negative for
SARS-Cov-2.
The world of science is on the race to discover a remedy for Covid-19, among them is the Artemisia-based treatment against Covid-19 (Covid-Organic) by the Malagasy Institute of Applied Research. With the very limited clinical trial of efficiency and safety of Covid-Organic, WHO warned the world not to consume any untested remedies for Covid-19 whiles encouraging more clinical trials into Madagascar’s Covid-Organic. The surge of new cases of Covid-19 in
Madagascar has resulted in the Malagasy Health Authority to re-institute lockdown measures. This has once again brought the efficacy of Covid-Organic (CVO) to the limelight even though the authorities still believe CVO is the miracle drug but yet to be proven by any scientific body of its efficacy against Covid-19.
Despite the high death rate (2.5%) by Covid-19, lesser than that of Ebola fatality rate at 60%, MERS and the 2003 SARS outbreak, it appears that efforts to find a definite cure for the deadly virus remain a challenge after several trials involving drugs already in use for the treatment of some medical conditions, notably ACE -2 inhibitors, antivirals, antibiotics, antiparasitics and steroids. At present hydroxychloroquine appears to be most promising, as published by the international journal of antimicrobial activity, and as such is been used in many countries across the globe. However, the drug has been reported to have been associated with cardiovascular disease events, as well as brain damage, hence needs review.
With the increasing spread of SAR-CoV-2 infection across the globe, there has been an increased interest in developing an effective SAR-CoV-2 vaccine that can protect the population. With the publication of the sequenced SAR-CoV-2 genome, research groups have been able to start SAR-CoV-2 vaccine adopting lessons from SARS and MERS vaccines development.
As of now, several vaccine candidates are in their various phases of clinical trials among them are the U.S government collaborative effort with Johnson & Johnson in developing Ad26 SARS-CoV2.S and the Moderna SARS-CoV-2 MRNA-1273 which has passed through it phase 2 trials and currently undergoing phase 3 clinical vaccine trials.
Although some vaccines have reached Phase 3 clinical trials and others been given orphan status, there is currently no vaccine against SARS-Cov-2.
The Socioeconomic implication of the Covid-19 pandemic
With the virus rapidly spreading and crossing borders, the most important strategy has been isolation and social distancing. As a result of which schools and business were closed. For many countries, movements were restricted and borders closed. The global economy has been heavily impacted through many interwoven factors including disruptions in global supply chains, supply shortages, increased prices of essential products, the collapse of stock markets, massive laying-off of workers, unanticipated increase in health expenditure and decline in tourism including non-operation of airlines.
There has been massive economic distress even in the most advanced countries. For example, a record of more than 3 million Americans have already filed for unemployment benefit claims and $2 trillion fiscal expansion package has been approved by congress to cushion the economy.
The economic impact of Covid-19 will yet hard-hit African countries with already low industrial capacities. The United Nations Economic Commission for Africa (UNECA) has predicted a drop in Africa 2020 projected GDP growth from 3.2% to 1.8 % due to Covid-19. The World Bank also estimated that a 1% decline in developing country growth rates will push as many as 20million people into poverty.
With the closure of hospitality industries, borders, schools and other requirements for maintaining social distancing at work, over a thousand jobs have been lost in Ghana. Most businesses have been heavily distressed requiring the government to intervene. This coupled with the unexpected increase in health expenditure has necessitated the acquisition of additional loan facilities by the Government.
With much pressure on existing health infrastructure and health workforce, many Africans will suffer the diversion of attention from chronic non-communicable and endemic infectious diseases such as malaria, HIV, Hypertension, Diabetes, Tuberculosis etc.
It is clear that Covid-19 pandemic has shaken the entire world affecting both lives and the economy but as the President of the Republic of Ghana said “We can bring the economy back to life but we can’t bring the dead back to life”, we can only hope to recover stronger to rebuild our economy and health care infrastructure.
The impact of Covid-19 pandemic is enormous but we cannot pretend not to see how it wholly exposed the poor health infrastructure and the absence of Emergency preparedness plan of 60years old Ghana.
Authors:
Edem, Nukunu (BS, M.D) 1 & Kwame Sherrif Awiagah (BSc, MPhil) 2
- He was an intern at Noguchi Memorial Institute for Medical Research (NMIMR) and currently serves as research Scientist for SARS-CoV-2 at NMIMR. He is also a member of the Medical Journalists’ Association – Ghana and a member of the World Federation of Science Journalist as well as a member of the Global Emerging Pathogen Treatment Consortium (GET-PLUS Faculty)
- He is Medical Virologist, Senior Nurse at Korle-Bu Teaching Hospital and a member of the Medical Journalists’ Association – Ghana. Reach out for Him via awiagahsherrif@gmail.com.
References
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NB: This article was first published by the Korle Bu Teaching Hospital Bulletin in August and September, 2020 respectively
