Hakim, Eluzai

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                                             Vol 13. (2) May 2020  South Sudan Medical Journal 51SPECIAL ISSUEcase management of severe COVID-19 illness, developing countries should focus on testing of all suspected cases and tracing the contacts to limit the spread of the disease.Acknowledgment: The author thanks Dr Edward Napoleon and Dr Nyagan Kalam Sakit for useful advice on technical issues. Financial disclosure: The author has reserved no funds from any institutions or individuals.References1. Team NCPERE. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) – China. China CDC Weekly. 2020; 2(8):113-22.2. World Health Organization, Director General’s Openning Remarks at Media Briefing, 11 March 20203. World Health Organization, COVID-19 4. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020. 5. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020.6. World Health Organization/WPRO WHO Korea Update accessed April 15, 7. Kuhn A. South Korea’s Drive-Through Testing For Coronavirus Is Fast — And Free. NPR, March 13, 2020. 8. Pueyo T. Coronavirus: why you must act now.  9. World Health Organization, WHO United States of America UpdateTesting for the virus is important, and when this is being carried out, explain to those tested why it is important. It is known that many infected people show no symptoms or signs of COVID-19, but they may be very contagious. Testing allows these asymptomatic people to be identified so they can be quarantined.  Some Non-Governmental Organisations have pledged sums of money to support resource poor countries to manage COVID-19. I suggest that a portion of this money be devoted to carrying out testing for the  coronavirus in those with symptoms, healthcare workers, the police, prison officers and prisoners, the army, airport personnel, civil servants, school teachers, bus and taxi drivers and those who come into contact frequently with members of the public.Testing and isolating asymptomatic people eliminated the virus in a villageSergio Romagnani, an Italian academic at the University of Florence[1]  carried out blanket testing in an isolated village of 3,000 people and found that 50-75% of people were asymptomatic for COVID-19, but these represented a “a formidable source” of contagion. After quarantining those who tested positive the number of people sick from COVID-19 fell from 88 to 7 in less than ten days.Hence, testing people is vitally important. According to Allyson Pollock,2 Professor of Public Health “Case finding, contact tracing and testing, and strict quarantining are classic tools in public health to control infectious diseases” According to the WHO, these methods have been painstakingly adopted in China. In Singapore and Vietnam meticulous contact tracing, clinical observation and testing were vital in containing the disease.[2]The South Sudan Household Survey (UNICEF 2006) stated that the average number of people per household was five. The potential difficulties of quarantining within this social set up could be challenging as most people live in the same room or “tukul”, made of  grass thatch and mud and wattle walled. The South Sudan COVID-19 High Level Task Force needs to come up with an innovative plan of quarantining the older person (>60 years) and those who test positive for the virus. The middle way is to test as many people as possible and isolate those who are positive in designated tents or low cost housing which can be erected rapidly using local building materials.References1. Day M. Testing and isolating asymptomatic people, “eliminated virus” in village. BMJ. 2020 Mar 23;368:m1165. doi: 10.1136/bmj.m1165.2. Pollock AM, Roderick P, Cheng KK, Pankhania B. Controlling the spread of COVID-19. BMJ 2020;369:m1284 Good Practice Pointer: Testing for the coronavirusEluzai Hakim, FRCP Edin, FRCP  Associate Editor, South Sudan Medical Journal

Good Practice Pointer: Testing for the coronavirus

South Sudan Medical Journal   Vol 13. (2)  May 2020                                                                      40SPECIAL ISSUEIntroductionCOVID-19 is the illness caused by a new strain of coronavirus first identified in Wuhan City, China in December 2019. It can cause a persistent new onset cough and a high temperature.Based on data from relatively more affluent countries coronavirus can cause more severe symptoms in people with weakened immune systems, older people (over 60 years) and those with long term conditions like diabetes mellitus, cancer, chronic lung disease and high blood pressure. It is not known if it will be the same in South Sudan. This is a new disease about which we have no previous experience. The situation is changing rapidly, as we learn more about it. So, we must expect advice to the healthcare professions and public to evolve. For now (April 2020) it seems that preventing spread of the virus using simple practices outlined below is the best way forward.  This article is intended to help healthcare professionals (e.g. nurses, midwives, doctors, therapists and laboratory technicians) advise the general public how to avoid catching the disease. It is based on guidance from the World Health Organization and other reputable organizations.The local South Sudanese COVID-19 Task Force has developed national guidelines for preventing the transmission of this disease. The advice in this article must be read and implemented alongside the national guidance. It is based on information from the sources listed at the end of this paper.Messages for health professionals to share with the publicKey messages to protect households from COVID-19 (see more below): • Wash your hands frequently• Avoid touching your eyes, nose and mouth with unwashed hands• Cover your mouth and nose if you cough or sneeze• Avoid close contact with people outside your household • Clean and disinfect frequently-touched objects and surfaces in your home. • If you have fever, cough and / or difficulty breathing, seek medical care earlyAlso:• Wear a mask in public if needed• Take extra care of vulnerable or sick people in your household• Stay informed and follow advice given by your healthcare provider• Continue to seek medical care for serious health conditions, and continue to take children for immunizations, continue to take routine medications, and to follow health education advice.Share, explain and discuss these messages with householdsPreventing the spread of COVID-19 in SouthSudanEluzai HakimAssociate EditorSouth Sudan Medical JournalCorrespondence: eluzaihakim@doctors.org.ukCitation:Hakim, Preventing the spread of COVID-19 in South Sudan. South Sudan Medical Journal 2020; 13(2):40-43© 2020 The Author (s)License: This is an open access article under CC BY-NC-ND                                             Vol 13. (2) May 2020  South Sudan Medical Journal 41SPECIAL ISSUEWash your hands frequentlyWhy? Washing your hands with soap and water (or using alcohol-based hand rub) kills coronavirus.• Wash your hands more often with soap and water for at least 20 seconds. Make sure members of your household and anyone entering your home do the same. • If you cannot wash hands with soap and water use hand sanitizer if available. • Wash your hands (see Figure 1): » after you blow your nose, sneeze or cough » before and after eating, and before, during and after you handle food, » before and after feeding a child  » after using the toilet » before, during and after caring for a sick person » when you get home or go into work  » after visiting a public space, including public transportation, markets and places of wor-ship » after touching surfaces or objects outside of the home or objects coming into the home, » after handling garbage » after touching animals and pets » after changing babies’ diapers (nappies) or helping children use the toilet » When your hands are visibly dirty.When explaining messages about COVID-19 with the public you may need to share this information about itCoronavirus has a fatty/greasy outer coat that is dissolved by soapy water or alcohol-based hand rub (hand sanitizer). The coronavirus (which causes COVID19-) is very infectious and lives in the nose and throat. If an infected person coughs or sneezes or spits the virus is carried out with the droplets and can cause infection in another person through their nose, mouth or eyes. The current view is that transmission is significantly reduced if people follow the other behaviours described below including keep at least two metres apart (“social distancing”).The droplets and virus may fall onto surfaces /objects and contaminate them and remain viable for up to several days depending on the type of surface. It is also shed in the faeces.  Coronavirus may not cause symptoms so a person who seems healthy may be infectious. • Use public hand washing facilities (e.g. at bus depots).Avoid touching your eyes, nose and mouth with unwashed handsWhy? Infected people may leave the virus on surfaces (e.g. door handles, utensils). If you touch these surfaces your hands become contaminated and can transfer the virus to your eyes, nose or mouth. From there, the virus can enter your body and can make you sick. Cover your mouth and nose with a tissue or in the bend of your elbow if you cough or sneezeWhy? The droplets sneezed or coughed out may carry the virus.• Cover your mouth and nose when you cough/sneeze with a tissue or disposable cloth then throw it into the trash or burn it, and wash your hands. If you cannot wash your hands straight away, avoid touching your eyes, nose and mouth. If you have no tissue, cough/sneeze into the bend of your elbow.Avoid close contact with people outside your householdWhy? If you are close to people in public places you can contract the illness. When someone coughs or sneezes, or even breathes heavily, water droplets spray out from their nose or mouth. If the person coughing or sneezing is infected (even if they are not showing any symptoms) the droplets contain the virus. If you are close, you may breathe in the droplets and virus. If you are infected you can pass the virus to others.Figure 1. From World Health OrganizationSouth Sudan Medical Journal   Vol 13. (2)  May 2020                                                                      42SPECIAL ISSUE• Avoid crowds, including football matches, religious events, and social gatherings of family or friends, especially in confined and poorly ventilated spaces. Follow your government instructions on crowd restrictions.• Where possible, keep at least two metres (length of a bed) distance between yourself and anyone you meet or walk near who is not in your household.• Do not shake hands or hug – safe greetings include a wave, a nod or a bow. These common social norms in our society must be avoided whilst the pandemic lasts.• Do not share items when in social gathering e.g. shisha, cups or bowls etc. Avoid communal eating, especially sharing the same gravy (“suruba”) by dipping maize or sorghum meal and “kisira” into the same dish using fingers which may not have been well washed. It would be better if people used  small individual dishes into which a share of the gravy or “suruba” is served for each person. This change in practice would reduce the spread of other infections such as hepatitis A and dysentery. • If possible, avoid the use of public/ shared transport. Try to travel at less busy times, keep a safe distance from others, avoid touching handrails or your face, and wash your hands as soon as you can.• Shop when shops or markets are less busy. Try to keep a safe distance. Wash your hands before and after you visit the shops / market and again after you have unpacked your shopping and put your shopping bags away.Clean and disinfect frequently touched objects and surfaces in your homeWhy? When an infected person coughs or sneezes or spits the virus can get onto surfaces like desks/tables. Anyone touching that surface can carry the virus to eyes, nose or mouth, or onto another surface.• Surfaces can be cleaned with soapy water or diluted bleach.If you have fever, cough and / or difficulty breathing, avoid contact with people outside your household. Seek medical care if symptoms are severe Poster with COVID-19 prevention messages in South Sudan (Source: Frederick Tawad)Why? National and local authorities will have the most up to date information on the situation in your area. Calling in advance will allow your health care provider to quickly direct you to the right health facility. This will also protect you and help prevent spread of viruses and other infections.• Stay home and do not travel if you have mild flu-like symptoms. Do not go to school, to work, or to other public places until you are completely free of all symptoms.• If you have more severe symptoms go to a medical facility. If you have a fever, cough and / or difficulty breathing, seek medical attention and call beforehand if possible. Immediately notify the first person you encounter that you are worried that you have a respiratory infection. Follow the directions of your local health authority.• Most people in South Sudan live in big, often multi-generational, households. It is likely that members of a household will infect each other. Staying at home for 14 days after the last person in the household thought to be infected will reduce the risk of the household passing the infection to others in the community.• Evidence suggests that people who develop symptoms are very unlikely to infect other people beyond the 7th day of illness, so these people may be able to return to some of their normal activities at this point, but should follow any government guidelines. Wear a mask in public places if neededAt time of writing there is no firm WHO guidance on masks although, increasingly, people are wearing them in public places in many countries. So check the latest advice                                              Vol 13. (2) May 2020  South Sudan Medical Journal 43SPECIAL ISSUEfrom your government, Africa CDC and WHO advice on masksMasks should be worn in public if you are coughing or sneezing, or if caring for a person with COVID-19. Masks might protect you in crowded public places from coronavirus droplets from infected people. However, masks must be washed frequently as the outside of the masks may have become contaminated.  They may be uncomfortable and hot, and give a false sense of protection. Wearing a mask DOES NOT MEAN THAT OTHER PRECAUTIONARY MEASURES CAN BE REDUCED. Masks can be made from layers cotton fabric, scarves or t-shirts, and must fit well. Surgical masks are needed by health and other frontline workers.Take extra care of vulnerable or sick people in your householdWhy? Some people are at increased risk of developing a serious illness from COVID-19 infection. These include older people and those who have underlying illnesses such as respiratory diseases, cancer and are undergoing cancer treatment, diabetes mellitus, and those who are HIV+ve and are not on effective treatment.• If possible, these individuals should stay at home and take extra precautions such as keeping a safe distance from others in public, and washing hands often if they have to go out.• Just one person should look after the sick person; if you need to share a bedroom with someone who is sick, make sure the room has a good air flow; try to have at least two metres between beds or sleep head to toe or put a curtain between the beds.• The sick person should not prepare food and should eat separately.Follow advice given by your healthcare providerWhy? National and local authorities have the most recent information on COVID-19 in your area and can advise you what you must do to protect yourselves.• Stay informed on the latest developments about COVID-19. Follow advice given by your healthcare provider, your national and local public health authority or your employer on how to protect yourself and others from COVID-19.Continue to seek medical care for serious health conditions, take children for immunizations, take routine medications, and follow health education advice.Why? The health service is for all medical conditions. Children who are not immunized may get measles (which can be deadly if combined with COVID-19) and other diseasesHow to share these messagesUse all forms of media to share and explain the key messages, adapting them to local conditions and beliefs, and national guidelines. As well as radio, TV,  posters, discussions and social media, enlist the help of community leaders, faith leaders and people in the media.  Materials used to prepare this paper• Africa CDC • Better Care Learning Programmes COVID-19 • Concern Worldwide. Advice to help prepare your household for COVID-19. • Health Improvement Scotland • Pan American Health Organization • UNICEF• World Health Organization• WHO Home Care Posters• CDC COVID-19 Households living in close quartersMaterials in graphic or video media• Picturing Health Coronavirus messages for communities. Video• The Slum and Rural Health Initiative (SRHIN): Stop the Spread of COVID-19• Ripple Africa. Coronavirus - Covid-19 - Simple Guide for Malawi  • WHO • Medicines for Humanity Acknowledgments: Mayom Biar Atem, Concern South Sudan, members of the SSMJ editorial team and others who helped to prepare this paper.

Preventing the spread of COVID-19 in South Sudan

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Good Practice Pointer: Testing for the coronavirus

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