COVID-19 induced fatigue lingers as frontline healthcare workers crack under the strain

Several reports have shown that the country’s Coronavirus disease (COVID-19) response has slowed down due to fatigue suffered by frontline health workers, states, and the Federal Government-led taskforces on COVID-19 as well as continuous disbelief by some Nigerians.

According to a study published, last week, in ScienceNews, “the unflappable health care heroes of the current crisis are beginning to crack under the strain. Doctors, nurses and other professionals are not only fighting an intractable virus day after day, they are also coping with isolation, shifting official guidelines, and limited ways to recharge.”

The study showed emergency medicine physicians report an average 60 per cent increase in emotional exhaustion and burnout over pre-pandemic levels. These workers cited the unavailability of protective gear, inadequate testing, and the risk of spreading the virus by discharged patients as their primary concerns. Physicians noted their stress levels have decreased their affection with family members.

High rates of depression and suicide in the medical profession have long been a problem but experts fear the coronavirus crisis will only make those numbers go up.

This photo taken on July 29, 2020 shows vehicles driving past an electronic billboard in Lagos, Nigeria’s commercial hub and epicentre of the virus in the country. – Five months after Nigeria saw its first case of COVID-19, the virus today is spreading at dizzying speed, posing a mountainous challenge to a health service already under strain. (Photo by PIUS UTOMI EKPEI / AFP)

However, medical experts who spoke to The Guardian yesterday said the situation in Nigeria is more of continuous disbelief than fatigue. They said with low testing, delayed test results, low case fatality report and a non-significant community spread tracing, people are wondering if the shutdown that has created an economic hardship was worth it. They said this seems to be enhancing the continuous disbelief that is manifesting as fatigue.

Director-General/Chief Executive Officer (CEO) of the Nigeria Centre for Disease Control (NCDC), Dr. Chikwe Ihekweazu, told The Guardian, yesterday: “It is not unusual that after six months of working nearly 24-7, many health workers and other staff involved in the COVID-19 response are experiencing some level of fatigue. This is not peculiar to Nigeria only. We are not only responding to COVID-19 but have to continue monitoring, detecting, and responding to other infectious diseases. For our frontline health workers, they are ensuring continuity of routine health services.”

To address the situation, Ihekweazu, who is also an epidemiologist and public health physician, said the NCDC is developing sustainable strategies at both national and state level to enable an effective response. He said they are at the final stages of disbursing additional funding to every state, through the NCDC/World Bank project. Ihekweazu said this has brought renewed energy to the response as states now have more resources to implement their response plans. “We have also deployed another set of rapid response teams from NCDC to support our colleagues in the state. The Africa CDC has been very supportive by funding surge staff at the community level in different states. With these plans in place, we are working very hard to ensure that our colleagues are well-resourced and energised to continue the response,” he said.

What are the challenges? Ihekweazu said in addition to responding to cases of infection and deaths, there are other challenges related to the response. He said one major challenge is infodemic- the spread of misinformation and fake news that can cause harm. “We are faced daily with rumours of fake COVID-19 cures or preventive measures, fraudsters taking advantage of people’s vulnerability and informing them of palliatives or funds provided by NCDC etc. These rumours distract health workers that are working very hard to quickly control this outbreak. They also set us back with the response as members of the public engage in self-medication or other dangerous acts due to these rumours,” he said.

To address the situation, the NCDC boss said: “We have established a very proactive communications campaign using traditional and social media, and urge Nigerians to take responsibility by only sharing verified information from NCDC, the Ministry of Health and other authorities.”

On how much each state has spent so far and the state of containment facilities in the states, Ihekweazu said: “One major output from this pandemic is the increasing investment in health security. Many states have risen to this challenge by providing additional financial and human resources for the health sector. They have invested in establishment of molecular laboratories, hiring of surge staff, establishment, and renovation of treatment centres, among others. We are still not where we want to be, but there has been progressing in the last six months. We will continue working with State Governments to sustain these investments so that we are better prepared for the next pandemic.”

Apart from funding issues, what other salient issues are paramount in states’ fight against coronavirus? Ihekweazu said: “At the moment, we are working very hard to increase both demand for and access to testing in many states. In some states, people are not showing up to get tested. There is the challenge of stigmatisation and also denial, where people do not believe the virus exists and is dangerous. In states with these challenges, we are working with them to rapidly scale up risk communications and community engagement.

“We need Nigerians to trust the public health system better and utilise the services we have provided. Similarly, we are working to increase access to testing in states. We have made available a grant to all states through the World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) project. These funds are to support them in strengthening their response activities such as establishing sample collection centres and taking the testing closer to people.”

What are the challenges of fighting COVID-19 in states? Ihekweazu explained: “The challenges faced in response to COVID-19 vary across states. In some states, we have difficulties accessing some LGAs, making it difficult for activities such as contact tracing to be carried out effectively. In other states, there is very poor adherence to public health and social measures.

“We are working with each state to ensure their response activities are contextualised. We are also learning from previous public health experiences such as polio vaccination campaigns, to develop innovative methods to reach inaccessible areas.”

Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib, told The Guardian: “It is pretty too early, given the epidemiological nature of the COVID19 pandemic. Every state has its own peculiarity and structure of handling the transmission of COVID19 in the state. However we at the NPHCDA are not tired, we have been very committed to supporting the states address the already happening community transmission of COVID19, which is part of our core mandate, and the states have keyed into this.

“Since the beginning of notification of the first case we have developed COVID-19 emergency preparedness and response plan for Primary Health Care (PHC) and community levels, we have developed training manuals for PHC.”

Shuaib, who is also an epidemiologist and public health physician, said the NPHCDA has trained over 200,000 health workers and community volunteers to be able to provide a continuum of PHC services in all the PHC centers in this country.

He said the Federal Ministry of Health (FMoH) under the leadership of the Minister of Health, Dr. Osagie Ehanire, is providing the resources needed to fight COVID-19 in all the states, and their sister agency, the NCDC, together with their development partners are doing an incredible job in surveillance, testing isolation and treatment.

The NPHCDA boss said the NPHCDA has an incredible resilience within the agency rank and file to fight any outbreak. “Recall we are now four years without any case of Wild Polio Virus (WPV) and we were certified polio-free officially on August 25, 2020. Therefore there is no fatigue anywhere; I do not know what evidence you have that indicates fatigue in the states. The PTF is fully committed to supporting states to fight the pandemic and return to normal accepting the new normal. The economy is gradually being reopened and will pick up,” Shuaib said.

The epidemiologist said the major challenge is community transmission and they are fully committed to addressing that. “Apart from the training of PHC worker and community volunteers we’ve done, we’ve also developed the concept of Community Support Centers (CSCs) in the LGAs stating with the highest-burden LGAs in the high-risk states and the PTF has approved this and the states have keyed into this,” he said.

Shuaib added: “The other challenge is the lockdown globally which has affected critical supplies in the health sector of our country. Within our country, the lockdown has affected the economy especially the informal sector. Mass numbers of people that depend of daily jobs to feed their families are affected. However, we’re cognitive of this fact and that’s why Mr. President has approved the gradual reopening of the economy.”

The NPHCDA boss said it is hard to determine at this level how much each of the states has spent so far. “It is actually variable, for instance, what Lagos has spent is different from what Ogun, Federal Capital Territory (FCT) Abuja and Kano have spent. The Federal Government of Nigeria (FGoN) thru NPHCDA, FMoH and NCDC has committed huge quantum of resources to support states in fighting COVID19,” he said.

Shuaib said the COVID19 pandemic has affected every aspect of human life globally and this therefore has affected the global supply of the needed Personal Protective Equipment (PPEs), which is critical to delivery of health services. “There’s also the challenge of strict adherence to COVID-19 Infection Prevention and Control (IPC) guidelines, which we addressed through engaging our communities. We have deployed huge quantities of Information, Education and Communication (IEC) materials in various languages to support our communities on IPC,” he said.

Shuaib, however, said the rates of health workers infections in some states are very high and the testing rates also very challenging in some states. “Our core mandate is to stop community transmissions and we are committed to doing that,” he said.

A public health physician and Director General of Delta State Contributory Health Commission (DSCHC), Dr. Ben Nkechika, told The Guardian that the situation in Nigeria seems more of continuous disbelief than fatigue. “It is the significant disbelief that is potentiating the fatigue,” he said.

On the challenges, Nkechika said identified low testing and delayed test result. He said people are resorting to self help when they have symptoms similar to malaria and other health conditions and getting better without test to confirm if it is COVID-19 or not.

Nkechika said it is difficult to determine how much each of the states has spent so far and the state of containment facilities in the states.

He said apart from funding issues, healthcare infrastructure deficiency and healthcare personnel motivation challenges are other salient issues paramount in states’ fight against coronavirus.

Nkechika said the COVID-19 response should have been from the primary healthcare infectious disease intervention level. He said a “Bottom-Up” approach instead of a “Top Bottom” approach would have capacitated the primary healthcare service status for sustainability.

The public health physician said most states are taking leadership from their Abuja.

Also, medical experts have expressed concerns over the resumption of international flights. They fear the decision may lead to further spread of the virus and the importation of the deadlier strain of coronavirus. They are however divided on the best way to contain the situation. While some say all arriving passengers should deposit their international passports, be quarantined for 14 days, and tested for the virus, others say it is not necessary. The latter, however, recommended the introduction of rapid testing that can produce results within 10 minutes.

A virologist and vaccinologist, Dr. Simon Agwale, said: “I don’t think it is necessary to quarantine arriving passengers for seven or 14 days, but the government should consider introducing rapid testing at the airport for all arriving passengers where results would be available within 10 minutes. This should be in addition to asking intending passengers to undergo a COVID-19 test before departure. This test should have been conducted within 14 days prior to undertaking the journey.”

To Director-General of the Nigerian Institute for Medical Research (NIMR) Yaba, Lagos, Prof. Babatunde Salako, “Returning travellers are expected to observe self-isolation in their homes until the results of COVID-19 test is out, people who are negative can then leave isolation while those positive will continue isolation after review by physicians. The very sick among this group will require treatment at government or private facilities isolation centres depending on their choice. Collecting their passports is only as a check to prevent unruly behavior and force them to comply with the rules guiding COVID-19 management.”

Former President, Nigerian Medical Association (NMA), Dr. Omede Idris, said: “If the protocol that Nigeria plans to carry out for those travelling abroad and returning from abroad is religiously applied, it will suffice. There should be a certified Polymerase Chain Reaction (PCR) test report while going and when returning. This should apply to foreigners coming in too.”

Medical Director of Optimal Specialist Hospital Surulere Lagos, Dr. Ugochukwu Celestine Chukwunenye, said: “Of course, the easiest, cheapest and safest option is to quarantine all arriving passengers for 14 days. That way the resident population within the country would be safe. Our immigration officers and other security officers will be able to implement this policy with ease. Taking hold of their passports will be so effective and inefficient, that the resident population will be facing grave dangers of being massively infected.

“It is the living any way that will bother about passport, and passport racketeering is not a new business. I very strongly recommend quarantine of all arriving passengers.”

A biomedical technologist at the Federal University of Technology Owerri (FUTO), Imo State, Dr. Chidi G. Osuagwu, said: “The COVID-19 problem is something people should take seriously! There are lots of conspiracy theories, and reasons not to dismiss some of them. There are lots of misanthropes who actively want to wipe off the black race and are embarrassed that the disease is not taking as much toll here as they hoped.

“The situation in Nigeria is not as bad, not our government’s responsibility, but because of the similarities of malaria and COVID-19 symptoms. And available malaria drugs, chloroquine, and artemisinin can both treat the early stages. We should not push our luck too far.

“Anybody entering Nigeria should be quarantined for two weeks, minimum. That is what serious countries like China are doing. Because Nigerian officials are easily bribed, the best option would be to maintain the lockdown. Moreover, our reckless people from the Diaspora would bring the virus from wherever they are, and not mind who gets it. Extreme caution should be advised.”