Tricky math of reopening: What Kenya can learn

It is now three months since the first coronavirus case was reported in Kenya and the country is trying to choreograph a risky dance: how to ease restrictions without importing another burst of uncontrolled contagion.

President Uhuru Kenyatta has made it clear that he is eager to restart the economy after partial lockdown measures shuttered factories, halted travel and kept millions of people largely confined to their homes.

As he sought a way to breathe life into the economy by easing the restrictions, he admittedly said experts warned him that this will be detrimental to the country.

The reduction of curfew hours and lifting cessation of movement in various counties was, however, a significant step for the country that is yet to reach its peak or even establish enough facilities for isolation of patients.

It was a government move to match steps taken by African peers in tentatively trying to end weeks of virtual lockdown.

MORE TESTS

Neighbouring Uganda started lifting some of the restrictions on June 4, two days later the country had reported an increase in community transmissions with their Prime Minister stating that he was in isolation after his staff was confirmed to have the virus.

When Ghana locked down its two major cities, Accra and Kumasi, in late March, officials began rapidly ramping up testing for the virus and tracing of people who had come into contact with those infected. That gave the government the confidence to begin easing the lockdown on April 20, well ahead of much of the rest of the continent.

Cases in Ghana spiked from 1,042 on April 19, the day before restrictions eased, to 6,269 a month later.

The lifting of the cessation of movement in the two states in Ghana was to their detriment and such instances have also taken place in other countries.

Over the weekend, Health Principal Secretary Susan Mochache said this was a key reason for not reopening the counties that are considered high risk such as Nairobi, Mandera and Mombasa.

Germany, which recently took its first steps in easing restrictions, reported that its reproduction number, which shows how many people a single person can infect with the virus, has risen to 1.1, hinting at the exponential spread, the American media House CBS News reported.

Pakistan is currently considering locking down yet again after they lifted their prolonged lockdown late last month in the country that already had a weak health system.

By June 6, Pakistan broke its previous record of the highest single-day deaths ever from the coronavirus disease, reporting 97 fatalities over a 24-hour period. With the latest surge, the death toll Pakistan has reached 1,935.

With 4,734 new cases over the last day, Pakistan’s number of coronavirus cases has reached 93,983, already surpassing China, and landing the country in the 17th spot in terms of Covid-19 cases, data shows.

South Africa, which is currently amid a phased easing of its shutdown — which began on March 26 — has also unveiled a $26 billion stimulus plan it hopes will reverse some of the harm done by its restrictions.

On March 26, the country shut down, with only grocery stores, pharmacies and essential service suppliers allowed to operate. The sale of alcohol and cigarettes has been strictly banned and South Africans have only been allowed to leave their homes for essential reasons, with the security services enforcing the regulations brutally.

However, despite such strict measures, the number of cases has continued to grow, with more than a third of the country’s 22,000 infections occurring in the last week.

Experts say with every phase of reopening, more movement means more risk and more work not only for governments but also Kenyans.

Prof Omu Anzala, an epidemiologist who has led Kenyan research into an HIV vaccine for decades, said Kenya had not reached its peak and the country could not reopen under the current circumstances.

“We aim to first flatten the curve, so that the health system is not overwhelmed. This is not the time to relax any of the measures,” said Prof Anzala, a researcher at the Kavi Institute of Clinical Research at the University of Nairobi.

While there is no consensus on how to reopen the countries across the world, the remarks by Prof Anzala hold for countries such as China and New Zealand which waited for the curve to flatten before reopening the country.

ZERO NEW CASES

Reopening of a country is complicated and while there is no template, the world can look to countries like New Zealand which has flattened the curve before considering reopening.

As of this past weekend, New Zealand had not recorded a new case in 15 days. The country, which has a total of 1,504 cases and 22 deaths, announced to lift restrictions on Monday. The country’s health officials have said only one active case of Covid-19 was being cared for at the hospital. The health ministry told the Guardian elimination of the coronavirus disease could be declared 28 days after the last confirmed domestic case of the illness had left quarantine, which would be on June 15.

On March 25, when the country had just over 200 cases of Covid-19, New Zealand imposed a strict shutdown, a move authorities say is to thank for the low number of cases. Prime Minister Jacinda Ardern said their plan of testing early had also paid off.

Dr Jacqueline Kitulu, President of the Kenya Medical Association, said it would be premature for the country to start considering lifting the restrictions especially since the government testing strategy has not been in line with their recommendations. Further, the government had also not been able to keep pace with the rate of transmission of the virus in the community, she said.

These, coupled with the fact that there was already a huge backlog of unprocessed samples due to shortages of reagents, made the testing programme look disorganized, thus affecting public confidence in the process, she added.

“As a result of the foregoing, it is clear that the government cannot conduct significant community-based testing that would help keep track of the transmission of Covid-19 in the country,” she stated.

According to her, any consideration of easing movement restrictions and reopening of schools, entertainment facilities and religious establishments must acknowledge the risk of a very rapid escalation of patients visiting hospitals due to both Covid-19 and other causes, with the attendant risk of overwhelming the health system and causing many preventable deaths.

“We, therefore, recommend that any such action only be considered after the measures enumerated above, and others previously recommended by the association to strengthen the health system, are instituted,” she said.

These were part of the reasons the President said he could not ease the measures set up. President Kenyatta said Kenya had not met the blueprint endorsed by the World Health Organization (WHO) which attempts to help guide countries toward this next phase.

The advisory by WHO describes a general trajectory that includes rapidly increased testing, which could inform localised strategies to respond to specific transmission patterns.

The WHO guidelines also recommend proper contact tracing ahead of reopening. Already, the Ministry of Health has raised concerns about those being tested giving inaccurate contact information, making tracing harder. The ministry said in areas of Mombasa and Nairobi they had been unable to trace the contacts of those who had tested positive for Covid-19.
Vulnerable populations

Last week, Health Chief Administrative Secretary Rashid Aman said some of those who tested positive could not be reached on phone, endangering lives. “Once the results are out, such individuals become unavailable. This is serious considering some of them have tested positive and we are unable to trace them,” he said.

However, the ministry has said it is setting up a mobile laboratory in Namanga for truck drivers, who have been blamed for bringing cases into the country.

For countries that plan on easing restrictions, WHO also proposes putting measures in place to minimise transmission in hotspots such as workplaces and schools. The agency advocates provision of equipment that makes social distancing viable. This strategy could be helpful as Kenya plans to start reopening schools in September.

Another guideline is to provide financial and other support to most vulnerable. In Kenya, populations living in the slums have been seen as vulnerable because of the challenge most face in observing some of the measures put in place to curb the spread of Covid-19. This is because most slums are congested, making it hard to observe social distancing. Such areas also lack water and proper sanitation services.

According to a report by Oxfam International on the global economic impact of the disease, the pandemic will mostly affect poor populations. The report shows half a billion people globally will be pushed into poverty. A majority of Kenyans either live on less than two dollars a day or are unemployed.

BED CAPACITY

The three measures the President said would determine if the country would ease lockdown involve a review on the effectiveness of the containment measures rolled out to break the chain of viral transmission. The other is to secure the undertaking of every county government to deliver isolation facilities with at least 300 bed-capacity and, finally, to develop time-bound protocols for progressive reopening of the economy.

So far, Kenya’s bed capacity has been way below its target. Counties such as Siaya, which has a 10-bed isolation unit for coronavirus patients, will be required to set up a 300-bed capacity in 30 days despite failing to do so in the last 90 days.

All eyes are now on the government to see if the measures Kenya intends to achieve by the end of the 30-day extension will be met.

The decision against reopening the country was also informed by the modulations made by experts who say in the worst-case scenario, 45,000 people will die of the virus should the restrictions be eased fast.

The President gave three scenarios which showed that, by October, Kenya would be getting into the peak of infections with 450,000 cases if the government relaxed the ongoing measures of curfew, partial lockdown and ban of social gatherings by 60 per cent.

He added that if these measures were relaxed by 40 per cent, there would be 40,000 deaths from 300,000 infections by November. Relaxing the restrictions by 20 per cent was no better as there would be 200,000 infections with 30,000 deaths by December.

Kenya, much like the rest of the world, feels the pressure to adopt comprehensive post-lockdown strategies this is amid evidence that without a vaccine, Covid-19 could “smolder in transmission hotspots” for years, according to Matshidiso Moeti, WHO’s regional director for Africa.

She said countries like Cameroon, South Africa and Algeria, and also smaller nations, will need to be able to rapidly detect and contain flare-ups or risk seeing their health services regularly overwhelmed with Covid-19 patients.

Here in Kenya, it is still too early to know whether the increased activity will mean new waves of infection. However, social distancing has proven one of the most effective means to curb the spread of the virus.

Even in the absence of an agreed way to reopen the country, there is scientific consensus about a general approach that can reduce the spread of the virus.

Kenyans are already tiptoeing towards normalisation with many opening up businesses and now working late after the curfew hours were extended.