SPA Global
Perspectives on COVID-19 from Nigeria and Kenya
By J. Matthew Kynes, MD
Pediatric Anesthesiologist, Monroe Carell, Jr Children’s Hospital at Vanderbilt
Nashville, TN
Olurotimi Aaron, MD
Consultant Anesthesiologist, Obafemi Awolowo University Teaching Hospital
Ile-Ife, Nigeria
V. Mark Gacii, MBBS, MMed
Pediatric Anesthesiology Fellowship Director, University of Nairobi
Nairobi, Kenya
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Dr. Kynes |
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Dr. Aaron |
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Dr. Gacii |
The most remarkable feature of SARS-CoV-2 has been its rapid emergence from an unknown virus to global pandemic in a matter of months. It has now impacted every nation on earth, although due to a range of social, medical, economic and other factors that impact has not been felt equally.
To better understand the effects that COVID-19 has had on countries in Africa, this report from pediatric anesthesiology colleagues from Kenya and Nigeria recounts the current social and medical manifestations of the fight against this disease in their settings. Dr. Gacii is a consultant anesthesiologist at Kenyatta National Hospital (KNH) and director of the Pediatric Anesthesiology Fellowship at the University of Nairobi, which has been sponsored by SPA since its inception in 2013. Dr. Aaron completed this fellowship in 2019 and returned to his home institution in Nigeria where he actively participates in strengthening the practice of pediatric anesthesia at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in Ile-Ife, South-West Nigeria. Both are leaders in pediatric anesthesiology on the continent and partners with SPA in advancing the field for the children and clinicians of their respective countries.
By the Numbers
Kenya has a population of 53 million, and as of July 28, 2020, had reported 18,000 cases of COVID-19 with 285 total deaths. Nigeria has a population of 206 million, and on the same date reported a total of 41,180 cases and 860 deaths since the start of the pandemic. According to the Africa Center for Disease Control, testing across the continent has been performed at much lower levels than in other parts of the world, with only 685 tests per million people compared to over 22,000 in Europe.
Surgical Volume
At both KNH and OAUTHC surgical volume has decreased by more than half since the public response to the pandemic began in March. Only emergency and urgent surgeries have been done, which includes many urgent neonatal conditions. At KNH only half of the 24 operating theatres are open at any one time and patient testing has been implemented for all major cases the day before theatre. Testing was initially done within the Kenya Medical Research Institute in Nairobi, but in June it transitioned to in-house testing at KNH.
Several cases of incidental finding of positive patients have occurred in patients brought in with trauma, some whom showed unusual respiratory signs in the post-operative period. While N-95 masks are mandated for inpatient care, there have been cases of staff exposure that require quarantine as a precaution. In Nairobi, there have been no documented cases of staff infection through patient exposure.
Anesthesia Training
Out of concern for resident safety, training in both countries was badly affected in the initial two months with duties restricted to ICU care only while operating rooms were completely run by consultants and qualified Clinical Officer Anesthetists. At the University of Nairobi, a rapid shift to online didactic learning was accomplished within about two weeks after operating rooms were closed. In fact, the attendance has been better than during physical classes due to the more flexible scheduling afforded by online lectures.
While scientific seminars at OAU have transitioned to virtual platforms, it has been more difficult to establish a virtual platform for resident teaching. Didactic teaching can only accomplish so much however, and both institutions are actively seeking ways to safely incorporate trainees back into the work environment even with the limited surgical volume currently present.
The other thing that has been affected is the timing of certification examinations. Kenya has recently introduced an online exam, but adjusting to this platform will be a challenge especially in the practical exams like the Objective Structured Clinical Examinations. Postponing exams which typically take place in the third quarter of the year could ultimately mean extending training duration.
Health System Preparations
Since June, COVID-19 case volumes in Kenya and Nigeria have begun to accelerate prompting concerns about a surge of the pandemic. In Kenya, at a national level, preparation for this has included each of the 47 counties setting up dedicated isolation wards, dedicated quarantine centers and increased ICU bed capacity. Kenya has a baseline of 537 ICU beds for the country with far fewer ventilators and qualified staff. Nigeria has fewer, only 350, for a considerably larger population. Funding from the national government was distributed to counties to help meet these needs and to bolster infrastructure and supply including of personal protective equipment (PPE).
At a local hospital level in both countries, virtual training among hospital staff has helped establish best practices and all anesthetists and ICU staff are recommended to wear N-95 masks, face shields, gowns and gloves during aerosol-generating procedures. Although initial PPE supply in Kenya was limited, this has been improving. In Nigeria, financial constraints (including price gouging) and logistical challenges have made procurement of appropriate PPE more difficult with staff required to furnish their own protection in some cases.
Indirect Effects
As in other settings with significant social restrictions, health seeking behavior in Kenya and Nigeria have been reduced significantly. This is due in part to a widespread public perception of risk of SARS-Cov-2 exposure from visiting health facilities. This means many people with chronic illnesses are not coming in for their routine follow-up visits and, anecdotally, many are even dying at home.
Compared to Western setting, the Kenyan and Nigerian economies are more cash-based and informal which has a dual effect. It means that although job losses have been very high, there is a large informal sector that continues to make a living, albeit limited. The hotel and tourism industries have been extremely stressed, with airline and transport industries strained considerably, as well.
In Kenya, from mid-March through April, the country’s two largest cities (Nairobi and Mombasa) were locked out from the rest of the country, and a strict nightly curfew starting at dusk was imposed to reduce the number of people going out to socialize. Generally, there is good compliance with these measures. As an example of the social implications of the disease, COVID-positive patients are buried by the government in a very hasty manner, which has not been well-received by the general public.
Opportunities to Collaborate and Support
One notable aspect of the global nature of this disease has been an appreciation of the greater need for global collaboration and support to combat this and other issues. The main support that anesthesia colleagues can offer each other is the sharing of useful information. Forums like the Safe Pediatric Anesthesia Network (SPAN), a global pediatric anesthesiology WhatsApp group, local and international anesthesia societies and other groups are extremely helpful during this time because they help dispel fear and allow real-time acquisition of the latest knowledge. This proliferation of resources has been remarkable and hopefully will lead to lasting change in the way we collaborate to address healthcare challenges in the future.
Conclusions
Governments around the world are now making the hard decision to open up socially and economically even as the number of cases is going up. While this is positive in that the initial sense of panic is subsiding and economic activity is increasing, this introduces inherent risks to society and healthcare systems.
As in any country, our hope is that populations in Kenya and Nigeria will take sensible basic precautions that have already been shown to reduce spread and that through innovation and cooperative we will keep further disruption and mortality at bay. Now, more than ever, it is clear that as a global community we are all in this together.
