COVID-19 In Low-Middle-Income Countries – March 2020 guidance

This unchartered COVID-19 crisis calls for universality and adherence to public health principles which include messaging, testing, isolation, treatment and access to a robust health system.   

Particular attention to pregnant women, and those with comorbidities will be needed to reduce the global impact of Covid-19.  In Low- and Middle-Income Countries (LMIC) the greatest challenges will be the lack of infrastructure and resources, whether those resources are natural, human constructed, or long-standing inequities.  Such challenges will be magnified when resources are limited.  It places even MORE need for effective prevention strategies.

Water and sanitation for hand hygiene

COVID-19 is spread through droplets released from infected individuals, and these droplets can land on surfaces, lasting for days depending on that surface.  Contact with contaminated surfaces, placing hands to face, and close contact with other individuals spread the virus readily.

We should heed the clarion campaigns to breaking this cycle, including the WHO “SAVE LIVES:  clean your hands “ and “Nurses and Midwives: clean care is in your hands.”  

International and national guidelines advocate for hygiene, but compliance is wanting even in health facilities .  In LMIC the challenges of access to clean running water can be overwhelming and include both absence and urban rationing; constraints associated with settlements; geographic areas (arid and semi -arid); climate change with reduction in rainfall and prolongation of drought seasons; lack of water harnessing and storage;  distances traversed to fetch water; restriction of water per household;  and amongst vulnerable populations such as refugees, the elderly, and street populations. 

These social and environmental determinants are further limited by poor water quality, rationing, and constraints associated with affordability.  Health messaging needs to be appropriately formatted for the audience, both in education level and cultural sensitivity.

The ability of hand hygiene to reduce infections is related to reducing viable pathogens.  Thorough hand washing with soap and water for at least 20 seconds or the use of 60% ethanol and 70% isopropanol hand sanitiser can inactivate other forms of coronavirus that are similar to COVID-19.  The challenges in LMIC can be daunting, with hurdles such as access to appropriate, widely produced, distributed, and affordable sanitiser.    Even as we write this summary, we are hearing of price inflation in parts of Africa, where early preventive steps against COVID-19 can stop what is being experienced around the globe.

Social behaviour transformation 

Humans are social beings but key to defeating the COVID-19 pandemic is social distancing, confinement, and self-quarantine, public health measures that will be met with resistance in many LMIC countries, as we have seen around the globe.  Culture has a bearing on socialization and provides for shared values, security and discourse, including human rights. 

Social distancing can be associated with a disruption of the socio- ecological- economic environment. However, recognition of such barriers must be addressed directly and immediately to remove tension, financial risks, and failure to cope. LMIC livelihoods often reflect “hand to mouth” (minimum wage pay) industry, and any curtailed business or employment disruption can have ripple effects on access to basic needs. 

Health systems

Constraints of health systems pose a sizeable risk in the LMIC COVID-19 response.  A quick and thorough response with widespread, or universal testing for COVID-19 is critical before the virus spreads widely, accompanied by tracking and isolation. Testing is now based on triage questions about risk status, symptoms and co-morbidities.  However, with increased influx of persons from high risk areas of Covid-19; across border migration; infections amongst asymptomatic carriers, it raises the question on universal testing,  isolation and social distancing. 

Governments are putting efforts towards saving lives in the face of alarming escalation.  Health inequities under central or devolved governments will interfere with clinical governance, surveillance and response.  Expanding health facilities accompanied by cessation of elective procedures, quarantine care, adequate financial resources and provision of basic needs are key.  

Finally, adequate Personal Protective Equipment (PPE) and the safety of health care providers is vital.   Global shortages and prohibitive costs have impeded the response and placed health care workers at risk. An adequate supply of PPE; attention to their doffing, disposal and environmental protection; and processing of bio-hazard material are required.   Clearly civil society, NGOs and governments must be organized and mobilised to guarantee the health of staff and patients alike. The importance of public-private partnerships cannot be emphasised enough. 

LMIC have an opportunity to react and respond quickly to avoid the patterns emerging around the globe that threaten the work force and patients alike.