Debate rages over new NCDC guideline on discharge, home treatment of asymptomatic patients

• Shedding Of Live Virus Not Viable After 10 Days – New Research
• Medics Counsel Against Release Of Half-Recovered Patients, Urge Caution
• ‘WHO Inconsistencies Due To Pressure, Impatience’

The Director General of the Nigeria Centre for Disease Control (NCDC), Dr. Chikwe Ihekweazu, has explained that the newly introduced guideline for the discharge of COVID-19 patients was based on emerging scientific evidence that shedding of live virus is not viable after about 10 days.

This is just as the decision by the NCDC, Lagos State Government and Presidential Task Force (PTF) on COVID-19 to begin home isolation/treatment and early discharge of asymptomatic patients, based on suggestions that asymptomatic patients do not transmit the virus or are not so infectious, continue to generate debates.

The new guideline, which was released this month, provides that symptomatic patients would now be discharged at least 10 days after symptom onset and at least three days without symptoms, while asymptomatic patients can be discharged 14 days after the first positive test and would no longer have to wait for a negative test to discharge.

Besides, the guideline recommended that discharged patients should continue self-isolation one week after discharge at home, should be followed up in the first week of discharge and monthly for the next three months, should ensure adequate hydration and rest, and should be put on multivitamin supplementation.

Ihekweazu, in answer to The Guardian inquiry, said because Nigeria is dealing with a pandemic caused by a new virus, there is need to continually review strategies based on emerging scientific evidence.

He said: “New evidence emerged that shedding of live virus is not viable after about 10 days. Following this finding, the World Health Organisation (WHO) issued new guidance and subsequently, we did.

“This discharge criteria from clinical care will also take into account the patient’s condition, disease experience and other factors. The RT-PCR test may remain positive in some patients, detecting virus segments, however, these are not viable for transmission to cause disease in others. In deciding on the criteria for discharge of COVID-19 patients, the most important factor is the patient’s clinical status and his/her risk to others.”

He told The Guardian that while there is evidence that these patients may no longer transmit the virus to others, it is important that standard precautions are taken at all times, adding: “We advise Nigerians to continue adhering to public health and social measures in place.

“Please, wash your hands frequently with soap and running water, wear a face mask when outdoors and in public settings, avoid contact with sick people, maintain a distance of at least two metres between yourself and the next person.”

Additional information from the guideline said data from Singapore demonstrates that “viral RNA detected beyond 10 days is no longer infectious, as no viable virus is grown by viral culture.

“Also, re-infection cases who became PCR positive after discharge has shown no evidence of transmission to contacts and no detection of the viral replication through viral cultures. A negative PCR means that the virus can no longer be detected in the respiratory samples.

“A patient should be discharged by the managing clinician if the following criteria are
met: Symptomatic 10 days after symptom onset, plus at least three days without symptoms (fever and respiratory symptoms).

“Asymptomatic patient should be discharged from the COVID-19 pathway 14 days after the initial positive result (date of collection of sample). A negative laboratory test is no longer required to discharge a COVID-19 patient.”

On the NCDC’s target of increasing daily sample testing to 4,000, Ihekweazu said: “At the moment, we are testing an average of 1,500 samples daily across the country.

“However, we have 33 molecular laboratories with the capacity to test a minimum of 10,000 samples everyday. We are supporting all states to rapidly increase sample collection. Some states have developed innovative methods, such as establishing sample collection booths and centres, which we applaud.

“However, we must work together to find and test more cases to know the true burden of COVID-19 in Nigeria. COVID-19 is not a myth; over 4,000 people have recovered in Nigeria. Therefore, a positive test result is not a death sentence.

“We urge more individuals who have symptoms or may have been exposed to call their states for advice on testing, while we encourage states to rapidly scale up sample collection.”

The debate on whether patients who do not show symptoms or show only mild symptoms can transmit the virus to other people was fueled early this week by the comment by a WHO official that: “It is very rare for asymptomatic patients to transmit the disease.”

But the agency was quick to walk back the comments the next day by saying: “Much is still unknown.”

An asymptomatic person is someone with COVID-19 who does not have symptoms and never develops symptoms. Both scientists clarified that it is not the same as someone who later develops symptoms, who would be classified as pre-symptomatic.

The new position that asymptomatic COVID-19 patients may not transmit the virus sent shock waves throughout the world, much of which has been locked down for months for fear of spreading the virus by persons who show little or no signs of the virus.

The inconsistencies have drawn criticisms from physicians, others experts and confused Nigerians.

Indeed, the WHO has been in the eye of the storm in recent times due to some inconsistencies, especially on hydroxychloroquine and Chloroquine, China’s handling of the outbreak and comments on asymptomatic patients, making more people to lose confidence in the apex United Nations (UN) agency.

One of such is the Brazilian President Jair Bolsonaro, who has joined United States (US) President, Donald Trump, by threatening to cut her funding of the organisation, just as the situation has also divided medical experts.

Ihekweazu had earlier written on his Twitter account: “About 80 per cent of COVID-19 cases show mild or no symptoms at all. These cases won’t be in isolation facilities under normal circumstances.

“Asymptomatic patients are primarily isolated to prevent transmission of the virus, especially to their loved ones.”

Regarding the implications of early discharge and home isolation/ treatment of asymptomatic patients on the global fight against the novel coronavirus, a professor of Obstetrics and Gynaecology, immediate past director general of the Nigerian Institute for Medical Research (NIMR) in Yaba, Lagos and President of the Nigerian Medical Association (NMA), Innocent Ujah, said: “As you know, a lot still needs to be known about COVID-19, therefore it is not advisable for early discharge of patients who have not completely recovered from the disease.

“The scientific world has yet to fully understand the course of the novel coronavirus disease. I therefore, advise that early discharge should be discouraged.”

On the inconsistencies by the WHO, Ujah said: “I do not think people should lose confidence in WHO, as COVID-19 is a new disease, which no scientist has had a previous experience in studying in details, including its epidemiology, course and pathology.

“We need to be patient with WHO and scientists working very hard to know more about COVID-19 through research, including the immunology clinical trials and vaccine trials. It is unfortunate that too much pressure is being put on WHO and that appears to be why it may have been inconsistent in many of the guidelines developed. It is important that we wait for new findings on COVID-19.”

Consultant public health physician/epidemiologist, member of Lagos State COVID-19 Response Team and former chief medical director of Lagos University Teaching Hospital (LUTH), Prof. Akin Osibogun, said: “Truly, we cannot say we have known everything about this virus. Researches are going on globally to try and unravel the virus.

“The safest approach will be to test patients and once they are antigen negative, meaning the virus could not be detected from their nasopharynx, then it is most unlikely that they can transmit the virus, as you cannot transmit what is not there.”

Osibogun said his team had published a paper last month in the Pan African Medical Journal showing that the average length of hospitalisation in Lagos was 12 days and that included the average of three days between the first and second negative, adding: “Theoretically, therefore, it seemed that the average duration of recovery would have been nine days.”

The first published study on how the first 32 patients with coronavirus in Nigeria were treated showed that 75 per cent of them presented in moderately severe condition, while 16 per cent were asymptomatic. The most common presenting symptoms amounted to 59 per cent and dry cough constituted 44 per cent.

A consultant public health physician and Executive Secretary/Chief Executive Officer of Enugu State Agency for the Control of AIDS (ENSACA), Dr. Chinedu Idoko, told The Guardian: “…I believe in arriving at this, NCDC also considered the incubation period of the COVID-19, which is actually the maximum period between exposure to the virus (becoming infected with the disease) and the onset/ manifestation of clinical symptoms, usually between five to six days, but could get as much as 14 days.

“Part of the pressures resulting in these new approaches is a fallout of the overwhelming of the healthcare system, following increase in number of cases with associated reduction in bed spaces/isolation centres in some areas of the country. Part of the reason in having patients treated in isolation centres is because of the highly contagious nature of the COVID-19. If, therefore, that element of infectivity is empirically proven to be non-existent at any stage of treatment, then its management could actually be reviewed, like recovery from any other illnesses, especially when the material (infrastructure, drugs etc), financial and maybe human resources for its management have been overstretched and in short supply.

“That is exactly the situation we are facing, which has prompted the NCDC and relevant authorities to pursue this route of reviewing the management and discharge guidelines, especially when it appears safe to do so. This way, the discharged patients could now recover at home with continued supportive management.”

He said the implications on the recovery process would be minimal if the patients can effectively comply with medical advice of bed rest, continuation of any subsequent or necessary medications and general advice medically handed out during the process of recovery at home, noting: “I believe that as the patients are being discharged, the authorities would have also set up necessary follow-up routines in case of an unlikely relapse.”

Idoko further explained: “I believe it is safe for society, because the most defining aspect of the COVID-19, which has been a huge concern, is its high infectivity with associated morbidity (illness) and mortality (deaths). When this infectivity issue is settled, then its recovery process could be managed normally like other diseases.”

Asked if people are safe to have half-recovered patients around them, Idoko said once that element of infectivity is removed, the patients could safely recover at home, though still applying and maintaining all the safety protocols, and their household and people around them should be safe.

The physician said stigma was a major issue in early stages and still remains an issue in the fight and control of Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), advising that we do everything possible to deal with the stigma issues in COVID-19, as it is not a death sentence.

Current Director General of NIMR, Prof. Babatunde Salako, added: “I don’t believe any isolation centre will discharge a patient yet to recover, but an asymptomatic patient can be managed at home in self-isolation. This is becoming necessary as many cases are now being detected, with little spaces for admission.”

But Emeritus Professor of Physiology at the College of Medicine, University of Lagos and former vice chancellor of Olabisi Onabanjo University, Olusoga A. Sofola, noted: “There are divided opinions on issue of asymptomatic patients, as many believe that they hardly spread it. However, I believe that once COVID-19 positive, you must isolate on the principle of test, isolate and trace. It is probably safer for everyone that way.

“It may be difficult to manage COVID-19 at home, unless it is mild or asymptomatic, and in the case that complications arise or patient’s condition gets worse, testing should be readily available to keep monitoring if they are asymptomatic or mild.

“In addition, it will be necessary to monitor them in case it worsens. There must be proper rules on isolation/quarantine of such people. It may require the employment of monitoring staff to check regularly on the affected persons or if possible create a web platform through which all those on isolation at home can be reached frequently or as required.”

Sofola said a structure would have to be devised or put in place to ensure adequate and appropriate monitoring, especially in an epicentre such as Lagos.

On the issue of Chloroquine therapy, Sofola said the WHO advice was based on the Lancet paper of May 20 reporting that it is not better and possibly injurious because of its cardiac effects, which was a valid thing to do based on the publication, now retracted, adding that WHO did the right thing again to permit clinical trial with Chloroquine.

“More recent data are showing lack of usefulness of the drug in COVID-19.

WHO-bashing is just scapegoating; there are many capable super experts working in the institution, rather than picking on the Director General, Dr. Tedros Adhanom Ghebreyesus,” Sofola said.

Joint pioneer of In Vitro Fertilisation (IVF) in Nigeria, Medical Director of Medical Art Centre (MART) in Maryland, Lagos and adjunct professor at the University of Illinois in Chicago, US, Prof. Oladapo Ashiru, supports home self-isolation and treatment, saying it is now clear that COVID-19 is a novel pandemic and even WHO, US Centre for Disease Control (CDC) and others are going back and forth in their treatment protocols.

He said from numerous reports, COVID-19 can be treated at home at the early stage when the signs are headache, throat irritation, sore throat, fever, colds and other signs, apart from difficulty in breathing.