Dear Editor,
Firstly, we would like to commend the Government on some of the early measures that it has enacted to curb the spread of the highly transmissible COVID-19 infection namely temporary closures of borders and schools. Sadly some other actions which have been Gazetted on March 16, 2020 (Direction by the President Given under The Public Health Ordinance Cap 145) leave us puzzled at best and deeply concerned at worst.
Working in the health care system in Guyana for some time at various institutions and levels has given us intimate knowledge of both the capabilities and shortcomings of the public health system in Guyana. For an infection that is this highly transmissible with countries estimating an ultimate infection rate of 40%-70% of the population (premised on worst case scenarios) leaves us with estimated persons affected at 300,000 to 525,000. Suppose 10% requires hospitalisation and of those, 20% require intubation and invasive ventilatory support; this translates to 30-50,000 hospitalised and 6,000 to 10,000 requiring ventilatory support. These numbers may be underestimations in a country like Guyana where the prevalence of uncontrolled non communicable diseases (diabetes and hypertension) and heart disease along with worrying rates of HIV leave a larger proportion of our population at risk for severe infections.
Currently in the Guyanese public system there are two available ventilators and measures are being taken to procure a further 12 ventilators bringing the total to 14, thus only 0.2% of persons that may require ventilatory support would be able to access same. While we trust that the use of ventilators may not be in the majority of cases, this example serves to highlight the limitations of management of severe infections with life-threatening compromise to the respiratory system. To therefore withstand and curb the impact of this disease requires strength in public health governance measures and immediacy in action. Unfortunately, it is the opinion of the authors that the measures gazetted by the government on March 16, 2020 are impractical and unmeritorious for the following reasons:
1. The Ministry plans to do away with self-isolation even in the case of mild disease, for which the majority of affected persons will present with such symptoms. As is noted, the first measure is to “restrain, segregate and isolate persons suffering from the disease, or who may be likely from exposure to the infection suffer from the disease”. Due to the easy transmission of this disease and doubling time (i.e. amount of time it takes for the number of persons affected by the disease to double in number) of 2 days we are likely to have 100 persons affected by the disease in as little as 2 weeks. If the plan is to restrain or hospitalise these persons at one of the 4 earmarked facilities for this isolation of every person, do they have the number of beds to house these persons? We can safely say that the answer is a resounding no as the present facilities will inevitably become saturated in a matter of days or weeks. Further, doctors that are required to tend to these persons will have to don PPE (N95 masks and tyvek suits) which will severely deplete what I’m certain is an already insufficient quantity given that even first world countries with endless resources have had to use substandard protective equipment for their healthcare workers due to shortages. Owing to global supply chain interruptions, and travel restrictions, we may not even be able to replenish the supply, putting our health care workers on the front line at unnecessary risk even if PPE are used sparingly.
2. The global response to mild or asymptomatic COVID-19 disease is to have the patient self isolate past the period that they are able to transmit the disease. This is in places with a much larger number of hospital beds per population. Yet, we are mandated to the contrary. We suggest that instead of wasting our isolation capabilities, protective equipment and risk transmission to health care workers on people that can do so themselves, hospitals should only admit persons that absolutely require admission i.e. require medical supportive therapy that cannot be received at home.
Considering the very real reality that persons would not adhere to self-isolation measures and continue their daily routines, thereby risking others around, the Government should consider alternate measures, albeit draconian, to ensure compliance to self-isolation. In India for example, airport personnel are using voting ink stamps on the hands of persons that should be self isolated. If voting ink will not remain in place for the full length of the quarantine time, you can send health care workers to reassess every 5 days and replenish the ink if the person is still at risk of transmitting the virus. In France, forms are required to be filled out to justify the reason for leaving the home, failure of which results in a monetary fine. To this end, a registry must be kept of persons on self isolation and use law enforcement to do random checks on these persons and charge or fine them if found to be in breach of the quarantine.
3. Thirdly, in the 19th March edition of Stabroek News there is mention of Health Officials considering the use of an expensive medical intervention namely Inter-feron Alfa 2B to fight the disease. This medication has no validated medical evidence to support its efficacy and has not been used anywhere else in the world apart from Cuba. To date the only medication that has shown (with supporting evidence) promise is chloroquine and its derivatives. This is a much cheaper and readily available alternative. We implore senior health officials that prior to making such decisions adequate research be done and level of evidence be assessed thoroughly.
4. Most worrying of all, is the Minister of Health being afforded the power to “remove, disinfect and destroy the personal effects, goods, buildings and any other article, material or thing exposed to infection from the disease”. Firstly how can an inanimate object be exposed to an infection. Certainly they can be exposed to the virus but an infection is a body’s manifestation after exposure to the virus. Secondly, the virus can only live on certain surfaces for a limited amount of time which ranges from hours to 2 days (depending on the type of surface). Nowhere in the free world have such harsh measures been afforded to the government to destroy personal property and again we implore that these powers should not be granted here. In the pre-antibacterial age this may have been an appropriate way to prevent spread of contagious disease but in this day and age it is completely unnecessary. We suggest that authority be given to disinfect these items at most.
These are just a couple of suggestions that may help decrease the unnecessary burden on health care facilities and workers and curb the spread of the disease.
We have the advantage of having our first case of COVID-19 infection more than 3 months after the onset of the disease in China, therefore, we must learn from the countries that have been affected before us and are taking aggressive measures at curbing the spread (especially South Korea). If we try to reinvent the wheel Guyana, it will go horribly.
I also urge the population to take this pandemic seriously. While social media may allow for mixed messages, the reality is that COVID-19 is in Guyana, and we must educate ourselves and take all necessary precautions to avoid the rapid transmission.
Yours faithfully,
(Name and address supplied for
Concerned Medical Professionals)
