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LETTER TO THE EDITOR
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 707-708  

Challenges of COVID-19 case detection in a resource-limited primary care setting: A commentary


1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission17-May-2020
Date of Decision09-Jun-2020
Date of Acceptance03-Jul-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_261_20

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How to cite this article:
Michael GC, Aliyu I. Challenges of COVID-19 case detection in a resource-limited primary care setting: A commentary. Med J DY Patil Vidyapeeth 2020;13:707-8

How to cite this URL:
Michael GC, Aliyu I. Challenges of COVID-19 case detection in a resource-limited primary care setting: A commentary. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 5];13:707-8. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/707/300139



Dear Sir,

COVID-19 is a viral infection caused by the virus, SARS-CoV-2.[1] The disease neither has a confirmed treatment nor vaccine at the moment. The COVID-19 pandemic has stretched health-care systems worldwide beyond limits as they control the spread and mortality from it. National responses largely depend on the available resources for case detection, supportive treatment, prevention, and control of the disease. Unfortunately, the middle- and low-income countries of Africa are worse hit by the pandemic.[2] What is needed for appropriate response in some countries, for example, quantitative molecular machines (reverse transcription-polymerase chain reaction), personal protective equipment (PPE), and ventilators, have to be imported. There are increasing number of COVID-19 cases and deaths. For instance, in Africa, as at 10.00 CEST of May 1, 2020, a total of 26,663 cases and 973 deaths have been reported (WHO situation report), while at 19.00 GMT of the same day, the Nigerian Centre for Disease Control (NCDC) reported a total of 2170 confirmed cases and 68 deaths;[3],[4] however, at 10.00 p.m. CEST and GMT of May 16, 2020, 54,461 and 5621 cases and 1667 and 176 deaths were reported in Africa and Nigeria, respectively.[5],[6] There are media reports of mysterious deaths from acute illnesses among the elderly in Kano, Nigeria, of which many suspects are COVID-19 deaths. Primary care facilities as important portals for the detection of new COVID-19 cases must be ready to play this role, especially in resource-limited settings.[7] We share our reflection on the challenges of case detection in a Nigerian primary care setting [Figure 1].
Figure 1: Map of Nigeria showing Kano State (in brown). Courtesy: Wikipedia

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At the society/community level, local beliefs and cultural practices, for example, denial of the existence of COVID-19 even among literate individuals, constitute a challenge toward case detection. For instance, the belief that COVID-19 is a scam, a disease for the rich, or for the temperate countries is common. Public gatherings for birthdays, weddings, and burial ceremonies despite governments' ban on such activities is a manifestation of these beliefs. Therefore, individuals with such beliefs are unlikely to seek orthodox care if they have symptoms. In addition, there is growing stigma associated with the disease such that those with symptoms conceal them and sought unorthodox care.

At the medical facility level, preexisting infrastructural and workforce gap presents an important challenge. For instance, the current diminished size of primary care personnel from the increasing number of infected doctors and nurses or who have been isolated for different COVID-19-related reasons, closure of many private hospitals for lack of competence in handling COVID-19 cases, diminished patronage after treating COVID-19 cases, and infected solo-practice private practitioners have reduced access to care and case detection. The resultant excessive care demand at the few equipped public hospitals and the absence of appointment systems to regulate patient flow result in overcrowding of primary care service points. This makes it difficult to enforce physical distancing, increases patient frustration and the anxiety of becoming infected with the virus, and sometimes abandons the clinic registration process without consultation. Thus, opportunities to detect COVID-19 cases are therefore missed.

At the state (central) rapid response team (RRT) level, there are challenges. First, the RRTs (trained health-care personnel for the management of COVID-19) who were formed by a special COVID-19 taskforce have responsibilities such as receiving requests from medical facilities and individuals, reviewing suspected cases for possible collection of swabs, and further management as per protocol. However, these teams are often overwhelmed by the increasing number of suspected cases and calls in the face of the limited turnout of volunteers for this job. In addition, some team members have been infected and consequently isolated, further depleting their capacity. This results in delays in responding to requests, creates patient anxiety and frustration, and sometimes patients elope from the temporary isolation points into the community without being swabbed. Second, there are delays by the RRTs in attending to suspected cases due to the inconsistent availability of PPEs (gowns, goggles, boots, etc.) and swab kits. Similarly, at the NCDC laboratory, delays associated with inconsistent supply of COVID-19 kits and reagents and closure of the laboratory for decontamination following infection of staff by the virus have also been reported. These scenarios result in sample collection halt, some suspected cases abscond from isolation and are not traceable, while some die and are buried without being tested. Again, some samples collected when the laboratory is not operational are sent to the country's capital (Abuja). This takes days and sometimes a week to get the results.

In conclusion, this report shows that challenges exist in COVID-19 case detection in a Nigerian primary care setting. Effective community-centered education with engagement of community and religious leaders (as was done in the fight against polio), training/retraining of primary care physicians (private and public) on case detection and management, and development of rapid diagnostic tests for COVID-19 (that do not require sophisticated workforce and equipment to operate) could be important ways of obviating these challenges in this and similar resource-limited settings.

Financial support and sponsorship

The study was funded by the authors.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
    
2.
Michael GC, Aliyu I. Impact of COVID-19 pandemic on primary care research in a resource-limited setting: A commentary. Pan Afr Med J 2020;35:15.  Back to cited text no. 2
    
3.
World Health Organization. Coronavirus Disease (COVID-19) Situation Report-102. World Health Organization; 01 May, 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200501-covid-19-sitrep.pdf?sfvrsn=742f4a18_4. [Last accessed on 2020 Jun 04].  Back to cited text no. 3
    
4.
Nigerian Centre for Disease Control. COVID-19 Case Update. Available from: https://ncdc.gov.ng/. [Last accessed on 2020 May 02].  Back to cited text no. 4
    
5.
World Health Organization. Coronavirus Disease Situation Report-117. World Health Organization; 16 May, 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200516-covid-19-sitrep-117.pdf?sfvrsn=8f562cc_2.[Last accessed on 2020 Jun 04].  Back to cited text no. 5
    
6.
Nigerian Centre for Disease Control. COVID-19 Case Update. Available from: https://ncdc.gov.ng/. [Last accessed on 2020 May 17].  Back to cited text no. 6
    
7.
Sahu AK, Nayer J, Aggarwal P. Novel coronavirus: A capsule review for primary care and acute care physicians. J Family Med Prim Care 2020;9:1820-4.  Back to cited text no. 7
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