The Case for New Case Identification Strategies
The first case of coronavirus in Nigeria was on the 27th of February 2020 when it was reported that an Italian citizen working in Nigeria returned from Milan Italy to Lagos Nigeria. Since the index case, Nigeria has recorded 7526 confirmed cases, 2171 recoveries and 221 deaths as at 24th May 2020. However, it should be stated that the total number of tests carried out stands at about 43,328, which puts Nigeria’s test per capita rate at 21 per 100,000, significantly lower than other peer economies of like Ghana (627 per 100,000) and South Africa (951 per 100,000).
The testing rate is alarming considering there is evidence that community spread is widespread in some parts of the country and it is doubtful that current testing capacity would be sufficient to test and trace all suspects. Tracing is also made difficult due to the backlash from the prolonged economic shutdown necessitated by the pandemic. Nigeria is country with poor economic indices – a growth rate of 2.27% in 2019, down from a high of 6.22% in 2014, a GDP per capita of 2134.076 at 2018, down from a high of 3225.711 in 2014, unemployment and underemployment rates of 23.1% and 20.1% respectively and a poverty rate of 40.1%, and as such it would be difficult to sustain a prolonged shutdown affecting the livelihood of millions without risking mass protests.
Given these realities, the best strategy that can be employed by NCDC is targeted testing approach that does not restrict the ability of most citizens of the country to carry out their functions while devolving and decentralizing COVID-19 management and contact tracing to the nearest Primary Healthcare Center (PHC). While the National Primary Healthcare Development Agency (NPHCDA) has commenced capacity-building of PHC personnel, it is pertinent that testing is ramped up, alternatively, symptomatic screening algorithm with moderate to high index of sensitivity for COVID-19 is utilized as the first line of management.
Symptomatic screening algorithm protocol would be feasible in Nigeria, however, it would require instituting a screening mechanism which most Nigerians would have access to. Options for this would include either a phone-in assessment, walk-in assessments at health facilities, an online assessment using the numerous COVID_19 applications. While the options listed are viable, they do present some challenges. The use of GSM technology would be the best given Nigeria’s GSM penetration of 97.45% however, a call centre with the capacity to receive the numerous daily calls is currently lacking. The NCDC call centre is currently overwhelmed with calls, with citizens complaining of their inability to reach the NCDC despite calling numerous times. While COVID-19 apps are a good development, the number of citizens with internet access is limited. Finally, walk-in visits for screening without a triage mechanism might also overwhelm already fragile health systems given the poor doctor-patient and nurse-patient ratios in the country.
An alternative screening method accessible to a vast majority of Nigerians, prevents both the NCDC and the state health system from being overwhelmed, and can be easily scaled across the country has to be designed and operationalized at the shortest possible time as every day lost further exacerbates COVID-19 community spread, putting more lives at risk.