Honourable Pravind Kumar Jugnauth Prime Minister Republic of Mauritius
I wish to share out my views on actions which I feel need to be taken most urgently in the fight against COVID-19 in view of what I observe to be the situation locally and in the most advanced countries. I believe that it is important to add that my involvement at a strategic level in dealing with the H1N1 pandemic at a time when we had very limited experience in dealing with such situations has given me some insight and expe-rience in pandemic preparedness. The situation is very dynamic and it is likely that as I am preparing this document many measures are already being planned.
I have chosen to communicate through this Open letter as during these difficult times a letter addressed to the Prime Minister’s Office or the Ministry of Health and Wellness may not get the urgent attention it requires. At the same time I believe that it is a transparent way to define the magnitude of the problem whilst highlighting our difficulties and limitations. This would help to galvanize support which has already been forthcoming from the medical and health professionals at large, the Private Sector and all stakeholders.
The main objectives of our Strategy has to be such that we EFFECTIVELY prevent /delay entry and halt local spread of the coronavirus (SARS-CoV-2 virus) whilst at the same time we develop a Primary Health Care/Hospital Preparedness Plan to deal with cases as and when they arise and in particular in the event that we get widespread sustained community infections. Most countries across the world are facing such a situation for the first time. Most countries are unprepared. Mistakes will be made. But we have to recognize our mistakes, be humble, accept positive criticism, learn from the mistakes, take corrective measures and move on.
I would like to start off by making some observations and proposals about some of the basic but fundamental preventive measures:
1. Washing of hands: Though there has been tremendous sensitisation on washing of hands at regular intervals, insufficient efforts have been made to provide adequate facilities for this simple measure to be implemented at public places, offices, sites of work, schools and even ministries. We are here talking about just soap and water. Urgent corrective measures are required. During the H1N1 pandemic the pharmacy department prepared sanitisers and distributed them to all health care and medical workers.
2. Social Distancing: There is an urgent need for sensitisation for this measure to be implemented at Supermarkets and in public transports and in all other public places.
3. During the confinement period some countries are allowing physical exercise under specific conditions. Basically individuals are allowed to go out unaccompanied for walks, walking of dogs and jogging. We have a population with a very high prevalence of pre-diabetes and diabetes. Persons with these conditions and with no space or facilities for indoor exercise may experience deterioration of their diabetes leading to complications such as heart attacks if they are unable to execise for long periods of time.
4. We also need to facilitate planters to carry on with their activities under certain conditions whereby social distancing is maintained as this is beneficial both in terms of physical activity but it will also ensure that we get a continuous supply of fresh vegetables which is important for our health. We have to facilitate that this supply of vegetables is able to reach the population at places other than markets where social distancing may be maintained.
The coronavirus has now entered our territory. We need to detect it wherever it is, as soon as possible, to prevent further spread. So the following measures are proposed:
1. The message from WHO is crystal clear Test, Test, and Test every suspected case and isolate and treat and do contact tracing. We urgently need to considerably increase our capacity for testing. This can be done more easily with the participation of the Private Sector. Cepheid has just received emergency authorization from the Food and Drug Administration to use its testing machine called GeneXpert that can run tests for coronavirus in 45 minutes. I understand that we have the GeneXpert machine at our Central Laboratory. Staff can be rapidly trained to carry out these tests. We can rapidly increase our capacity for testing by engaging the Private Sector to also rapidly build its capacity for testing.
2. With our capacity for testing significantly increased, we need to urgently review our criteria for testing. Tests need also to be done on all cases of severe pneumonia, infective bronchitis and Adult Respiratory Distress Syndrome and other respiratory conditions, suspicious respiratory tract infections in the community. The decision for testing needs to rest with both the treating Specialist/Private Doctor and the Regional Public Health Superintendent. In case of disagreement, the final decision should rest with the Consultant in charge in Internal Medicine of the Region or the Consultant in charge of Chest Medicine. We need of course to continue testing in cases as per established criteria, for instance for contact tracing.
3. We urgently need to significantly reinforce our capacity for contact tracing in order to ensure rapid and effective contact tracing and testing.
4. Ideally we need to keep our borders closed throughout the pandemic. However this may not be possible for various reasons. It is anticipated that the pandemic may last for at least 6 months or even a year. There are two possible scenarios. We have either been able to control our local spread or not.
If we are in a situation whereby we are having sustained com-munity spread, nothing that we do at our borders will alter much our local situation.
5. If we have managed to control community spread or at best stopped it altogether, then when and if we re open our borders, we will need to quarantine all incoming travellers and test all travellers. We will have to quarantine travellers under strict conditions in designated hotels under the supervision of public health staff. It is proposed that International travellers be made to pay for the quarantine facilities and for testing. In order to win the war against COVID-19, we have to be always several steps ahead. We pray that we never reach the stage whereby we fail to prevent sustained community spread. But we have to start planning our primary care health service and our hospital response.
In order to do so we have to consider different scenarios based on the evolution of COVID-19 in other countries. It is estimated that COVID-19 affects 30-70% of populations. The good news is that 80% of the population affected has a minor illness and gets better and 20% needs admission in hospitals. Some 5% of the affected population needs intensive care treatment. The mortality rate is around 1%. There are slight variations in figures available in the medical literature.
We have an elderly population and a high prevalence of noncommunicable diseases. Thus I estimate that in a worse case scenario 40% of our population may be affected. Sustained community transmission, if it happens, will happen over a 3-4 months period.
The population of Mauritius is estimated at 1. 27 million people. So we may get around 500,000 people affected over a period of 3-4 months. Fortunately that 80% , that is 400,000 of these people will have a mild illness.
If we assume that 50% of the people with mild illness will treat themselves in the private sector, we will still need to provide for some 200,000 people with mild illnesses in our primary health care centres and hospitals. It will mean some 50,000 additional attendances per month which means around 1,600 attendances daily.
A decision will have to be urgently taken as to whether we will treat all our patients with no contraindications with Hydroxychloroquine. Research in Marseille, be it on a small number of patients, has shown that only 25% of patients treated with Hydroxychloroquine were carriers of the virus at 6 days compared to 90% of those not treated. I believe that treatment of all cases with no contraindications will diminish the transmission rate during sustained community transmission and possibly also the number of cases requiring admission or developing complications and deaths. During crisis situations like at present it may not be wise for us to wait for the evidence base to be well established before we take a decision. It appears that the United States and France will be using Hydroxychloroquine in most of their cases. It is likely that there will rapidly be a shortage of this medication on the World market.
Now we come to the major challenge. This is dealing with the 100000 cases who will need admission over say a 4 month period. The bulk of these cases would most probably be attending our public services. Let us put this number in perspective we get about 200,000 admissions per year in our hospitals. This will mean some 25,000 additional admissions per month that is around an additional 600-1000 admissions daily in our hospitals.
We managed to deal with a similar number of cases during the H1N1 pandemic but for the COVID-19 pandemic we may have to deal with very significant-ly more admissions. Here are the measures proposed :
1. We need to urgently start to educate the population about the different stages of our strategy and about basic initial management of the COVID-19. We also need to review our advice to the general public about the use of facemasks in the light of new evidence. Facemasks need to be therefore made generally available to the public at affordable prices.
2. As of now we need to plan out COVID-19 clinics within our primary care network. As far as possible patients should as from now be sensitised to eventually attend COVID-19 clinics in primary care centres of their region rather than attending the Accident and Emergency Department. The reasons should be clearly spelt out to them.
3. In the event that CO-VID-19 clinics are set up in hospitals they should be well away from the Accident and Emergency Department and from other crowded activity areas.
4. We will need to plan the timing of reconfiguration of services offered in hospitals and we will need to plan when to stop elective procedures and treatment during the sustained community spread period.
5. As of now clear proto-cols should be worked out for the management of mild and moderate cases of COVID-19 and these protocols should be circulated widely including to the health and medical personnel of the private sector.
6. We need also to work out the protocol for the management of severe cases needing admission and needing intensive care treatment.
7. We need to establish communication with the experts in China to learn from their experience. It would seem that they may advise us based on their experience we need to develop our protocols. All the health and medical personnel need to be urgently trained and provided with information for the management of these cases.
8. We need to re evaluate our stock in terms of medical and oxygen supplies, protective gear, medication, medical equipment in order to deal with such large number of patients. We may here need to seek the help of India and China for providing us with certain items of medical supplies in particular ventilators and Hydroxychloroquine if we do not have enough in stock. We have to ascertain that Hydroxychloroquine is readily available in all public and private pharmacies in sufficient amounts. The price of Hydroxychloroquine in private pharmacies has to be very reasonable.
9. We need to plan out the logistics for transport, catering and laundry for dealing with these numbers of admitted patients.
10. We need to consider the urgent creation of banks of recently retired medical and health staff who may be called in at critical times when up to 50% of staff may be absent due to contamination, illness, exhaustion or attending to loved ones who have fallen ill. These retired staff will need to be provided with top up training.
11. We urgently need to develop protocols to deal with dead bodies. We have unfortunately already had two deaths. We need not reinvent the wheel. The protocol of the Ministry of Health of India is available online. We just need to amend it in line with our local context. We also need to plan the logistics for dealing with the increased number of deaths which may arise.
12. We need to establish a clear line of communication with our staff working at grassroots level and their trade unions so that we respond to their queries and fears rapidly and effectively.
13. The population at large and all medical and health personnel need to be kept aware of all measures being planned and also of our difficulties and limitations. We have to transparently prepare our population for difficulties we may face in the future. In that way we will achieve the buy in and full participation of the population.
14. Most importantly we will need to plan for enhanced security at all our institutions.
15. The major challenge will be finding the beds for admissions. We may be getting 25,000 ad-missions monthly over a period of 3-4 months that is 600-1,000 ad-missions per day. We have around 3,700 beds presently in our institutions and there are 4,415 beds in the public and private sectors. We have to assume that we may only be able to use 3,000 of these beds exclusively for COVID-19. We will therefore need to start urgently to work out how we will manage to cater for such demands. We will need to look into the possibility of setting up negative pressure wards. We may now begin to understand as to why several hospitals were built urgently in Wuhan. I suggest that we discuss with the Chinese experts regarding our bed capacity requirements and we may even discuss with them about the setting up of required facilities rapidly.
16. The other major challenge will be meeting with the demand for intensive care treatment. It is estimated that 5% of COVID-19 patients require intensive care treatment. So around 25,000 patients may need intensive care over a 3-4 months period. I can only say that we have to urgently very very significantly increase our capacity for intensive care treatment. We will need to look into the possibility of setting up intensive care units with negative pressure facility. Here again I suggest that we tap into the Chinese expertise to advise us on our intensive care treatment capacity requirements and we may also seek their help for building up such capacity rapidly.
I wish to re-iterate that at this moment of an absolute public health emergency with its dire socio-economic implications I feel it is my duty to share my views. I very much hope that we may control and halt the community spread which has just begun and that we may never reach the point of sustained community spread. I also hope that if ever we have sustained community spread it happens to a much smaller scale.
I take this opportunity to wish you and your team plenty of courage during these difficult and challenging times.
Copy to: Dr the Hon Kailesh Kumar Singh Jagutpal Minister of Health and Wellness.