Zisis Kozlakidis and Dewi Nur Aisyah, explain the renewed focus on resource-restricted settings when it comes to COVID-19 infection prevention
The COVID-19 pandemic continues to exert significant pressures on healthcare systems globally. While the potential dangers this continued pressure poses to healthcare systems in high-income or upper-middle- income countries, the virus could represent a much greater epidemiological threat to lower-income countries in the months to come. The high risks in resource-restricted countries reflect combinations of common underlying characteristics: densely populated urban areas, high rates of self-employment with no sick pay, often poor community hygiene and sanitation, and weak health systems.
In addition, to the health systems’ limited infrastructure, they often lack adequate surveillance and laboratory capacity, a sufficient supply of appropriately trained health workers, and have utterly insufficient critical care capacity to address a sudden upsurge in severe COVID-19 cases. (1) Many of these challenges are chronic and were recorded previously in the context of infectious disease outbreaks, as they severely hampered the response to the Ebola outbreaks. (2) Here we take a closer look at the two main prevention strategies and highlight areas of concern and as such, opportunities for further improvement in resource-restricted settings.
“The high risks in resource-restricted countries reflect combinations of common underlying characteristics: densely populated urban areas, high rates of self- employment with no sick pay, often poor community hygiene and sanitation, and weak health systems.”
Behavioural-based prevention
Many of the strategies that have been widely deployed to reduce or control SARS-CoV-2 transmission are those based on behavioural patterns, such as the restrictions on population movement (e.g., lockdown), in daily routine and practice (e.g., hand sanitiser, masks, etc.).
One of the concerns during surges in COVID-19 cases is that the health systems themselves do not become a vehicle for viral transmission from infected individuals to other patients or front-line health workers. Whereas in many high-income countries the consistent advice has been not to visit a health facility if you have a fever or cough, in resource-restricted countries, this advice might be much less appropriate given the high prevalence of other potentially serious diseases with similar symptoms, such as malaria, pneumonia, HIV and tuberculosis. Having said that, reducing the contact points with healthcare is not a long-term solution as there are collateral implications on routine care, as for example, in the case of cancer patients.
“The COVID-19 pandemic continues to exert significant pressures on healthcare systems globally. While the potential dangers this continued pressure poses to healthcare systems in high-income or upper-middle- income countries, the virus could represent a much greater epidemiological threat to lower-income countries in the months to come.”
Such behavioural-based interventions can be effective; however, they are not without costs. One would need to add costs for resources for additional training and behaviour-change activities to support and monitor implementation, and in areas where the availability of trained staff is limited, this places additional pressures on the wider healthcare provision. Moreover, infection prevention and control for COVID-19 often requires many more actions than those originally intended. For example, the World Health Organization (WHO) COVID-19 guidelines require cleaning and disinfection of toilets at least twice daily by a trained cleaner wearing personal protective equipment (gown, gloves, boots, mask, and a face shield or goggles); once-daily cleaning of all environments in which patients with COVID-19 receive care, as well as cleaning when a patient is discharged; and wearing of appropriate personal protective equipment by all individuals dealing with soiled bedding, towels, and clothes from patients with COVID-19. The extremely inadequate availability of personal protective equipment in these health systems represents a major threat. 3 In response, countries, such as Indonesia have utilised digital health solutions to streamline behavioural- based prevention strategies, and thus allowing for a wider societal impact at a substantially controlled cost.
Vaccine-based prevention
As of 20th November 2021, 53% of the global population received at least one dose of the COVID-19 vaccine; however, this number masks a severe imbalance, as only 5% of people from low-income countries have received at least a single shot of a COVID-19 vaccine. Vaccine unwillingness was obvious in several resource-restricted countries during the inception phase of the current mass vaccination program against COVID-19. Often limited knowledge of the preventive advantages of immunisation and the lack of mass campaigns might be prominent reasons behind the observed scepticism.
In addition, the digital infodemic on COVID-19 grew further regarding the (many fantastical) adverse effects of COVID-19 vaccines, thus adding to the overall hesitation. Although this reluctance behaviour seems to have now subsided, the unequal global vaccine coverage remains a reason of grave concern. Even within low-income countries, there are reported inequalities, as urban areas often have a privileged vaccine availability (also due to the required cold chain logistics infrastructure); in contrast, to most of the rural areas. Having said that, in countries where the communities have been effectively mobilised through the involvement of community leaders in the planning and messaging of vaccination campaigns – as in the case of Indonesia – vaccination campaigns are more effective, though still insufficient for the size of the given population. (4)
Finally, the vaccine-based prevention strategy does not end at the provision of vaccines, as the WHO recommended post-vaccination routine surveillance, for potential adverse effects as well as potential new viral variants that might be able to escape the immune response facilitated by the vaccines. Therefore, a highly holistic, political, administrative and diplomatic progress must be achieved to acquire the desired levels of herd immunity and protection at the earliest possible time.
“Perhaps the pandemic would be the catalyst needed to genuinely build back better healthcare systems, systems that are at the same time more resilient, effective, and equitable.”
Recovery and rebuilding
According to the WHO and the United Nations Children’s Fund, the COVID-19 pandemic has impacted routine health services, such as routine childhood vaccinations, including many Asian and Middle Eastern countries, where many children continue to face higher risks in relation to outbreaks of vaccine-preventable diseases. For example, globally, the vaccination rate for three doses of the diphtheria-tetanus-pertussis (DTP) vaccine fell from about 86% in 2019 to 83% in 2020 and measles first dose, from 86% to 84%, respectively. As such, the COVID-19 pandemic recovery phase would consist of financial and social return to normality, as well as the necessity to re-establish existing routine healthcare operations. Perhaps the pandemic would be the catalyst needed to genuinely build back better healthcare systems, systems that are at the same time more resilient, effective, and equitable.
References
- (1) Powell-Jackson, Timothy, et al. “Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19.” The Lancet Global Health 8.6 (2020): e780-e789.
- (2) Shoman, Haitham, Emilie Karafillakis, and Salman Rawaf. “The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review.” Globalization and health 13.1 (2017): 1-22.
- (3) World Health Organization. Water, sanitation, hygiene, and waste management for the COVID-19 virus: interim guidance, 23 April 2020. No. WHO/2019-nCoV/IPC_WASH/2020.3. World Health Organization, 2020.
- (4) Aisyah, Dewi N., et al. “Laboratory Readiness and Response for SARS- Cov-2 in Indonesia.” Frontiers in public health (2021): 969.
Disclaimer
Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/WHO.
