Covid 19 pandemic control options in Afghanistan

1. COVID-19 Pandemic
Control options for Afghanistan
Najibullah Safi, MD, MSc. HPM
Sunday, May 17, 2020

2. Context
• Afghanistan reported the first case
on Feb 24, 2020, among the
returnees from Iran
• Close to 300,000 Afghan refugees
were forced to return since January
2020 from Iran
• The virus quickly spread to all
provinces, and community
transmission established
• As of the 17th May 423 healthcare
providers are infected and 11 died
with COVID-19 due to shortage or
inappropriate use of PPEs
• Mortality rate among confirmed
cases is 2.54%
22594 22592
6635
5688
169 778
19
0
5000
10000
15000
20000
25000
Collected
samples
Tested
samples
Confirmed
cases
Active cases Deaths Recovered Severe
cases
Status of COVID-19 as of 17th May
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3. Context cont.
17.3
16.6
13.9
10.9
8.6
7.4
4.9
4.6
3.7
3.3
2.6
1.9
1.7
2.7
% OF AFG POOULATION BY AGE GROUP
• Lack of consensus on complete vs.
partial lockdown
• No imposition of penalties for non-
adherence to lockdown
• Economic package for daily wagers,
unemployed, vulnerable population
• 4.5 kg wheat was distributed to
each low-income family through
Masjids; furthermore, 5 loaves of
bread two times per day are
distributed through bakeries to the
poor
• Afghanistan has a mostly young
population
• 67% is under the age of 25
• 48% under the age of 15
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4. Estimation of admissions and deaths for planning*
Most
likely
scenario
Minimum
scenario
Maximum
scenario
Pandemic
impact/attack
rate
25% 15% 35%
Total hospital
Admission
58,844 18,018 100,184
Total deaths 9,162 3,430 21,508
* CDC Flu surge software fluSurge2.0 for Estimated burden of covid-19 in general population and health system v2. April 01,2020
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5. Control measures
1. Country‐level coordination and response planning
2. Surveillance, rapid response teams, and case investigation
• Around 34,000 Acute Flaccid Paralysis (AFP) surveillance volunteers refer
suspected cases to health facilities and rapid response teams
3. Case management
• Support and equip isolation wards/ICUs in the designated national, regional
and provincial hospitals
• More than 12,000 hospital beds are available for COVID-19 patient across
the country
• Construction of new hospitals in Herat and Nimroz provinces
• Doubling ICU capacity (more than 400 ICU beds are currently available)
• Currently more than 480 ventilators are available, more to come in June
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6. Control measures cont.
4. Laboratories
• The country lab capacity for the diagnosis of COVID-19 increased from ZERO in
early Feb 2020 to 9 functional labs in five regions
• By 17th May 706 tests are done per million of population
• On average 30% of the tested samples were found positive
5. Points of entry (PoE)
• Support of health and other teams for screening at the PoE on ground crossings
and airports
6. Infection prevention and control (IPC)
• Support IPC at identified health facilities, isolation centers and designated PoE
• Train more than 1,200 health workers on case management, ICU, IPC (health workers,
support staff, cleaners, ambulance staff) in designated health facilities and isolation
centers
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7. Control measures cont.
7. Risk communication and community engagement
• Mass media campaigns using posters, billboards, TV, radio, and social media for
raising awareness on COVID-19
8. Continuation of essential health services (BPHS/EPHS)*
9. Operational and logistics support
• Regular supply of equipment and consumables
Non-pharmaceutical interventions
• Practicing frequent hand washing
• Following respiratory etiquettes
• Ban spitting in public places
• Lockdown and following social distancing
• Closing all public and private schools, universities
• Ban on all pubic gathering
*Basic Package of Health Services/Essential Hospital Services
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8. COVID-19 epidemic curve 25th March 16th May
0
500
1000
1500
2000
2500
25-Mar
27-Mar
29-Mar
31-Mar
2-Apr
4-Apr
6-Apr
8-Apr
10-Apr
12-Apr
14-Apr
16-Apr
18-Apr
20-Apr
22-Apr
24-Apr
26-Apr
28-Apr
30-Apr
2-May
4-May
6-May
8-May
10-May
12-May
14-May
16-May
COVID-19 epidemic curve - Afghanistan
Note: the fluctuation in number of cases for the last few weeks is due to unavailability of testing kits on certain days of week (no
test one day and then the following day the collected samples of two or more days were tested)
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9. Future potential options for the control of
COVID-19 in Afghanistan
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10. Control option I
• Strengthening and expanding control measures (all 9 interventions
listed earlier)
• Use effective prevention (vaccination) and treatment when become
available (not expected at least in 2020)
• Reinforce the continuation of all non-pharmaceutical interventions
described in earlier slides
Strictly enforce lockdown: seems extremely challenging as:
• More than 55% of the population live under the poverty line
• Around 66% of the population are engaged in informal employment than
non-agriculture sector (ALCS 2017)
• Reduced utilization of essential health services may result in increased
mortality (e.g. measles, diarrheal diseases, etc.)
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11. Control option I cont.
Strictly enforce lockdown:
• In the absence of social protection, the continuation of lockdown
significantly increases poverty, malnutrition, and hunger. It may cause
more mortality in the long term than COVID-19
• Relaxing lockdown in a later stage associates with a potential second wave
of disease with additional mortality
• By May 14 with strict lockdown in Spain only 5% of the population have
developed antibodies* (chance of the second wave of disease is much
higher)
• A survey in Kabul indicated a higher level of COVID-19 antibodies in the
blood (52% with RDT while 31% with PCR**)
• This could be a positive sign indicating rapid development of herd immunity as
compared to the countries enforced complete lockdown like Spain
* https://english.elpais.com/society/2020-05-14/antibody-study-shows-just-5-of-spaniards-have-contracted-the-coronavirus.html
** https://www.bbc.com/persian/afghanistan-52515282
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12. Control option II
• Strengthening and expanding all interventions under OPTION I except
lockdown
Gradually relax lockdown
• A proportion of the 66% Afghan population engaged in informal employment may
resume their work, which may slightly contribute to averting the increasing
poverty
• Utilization of essential health services may improve to some extent and get closer
to the pre COVID-19 era and slightly prevent deaths due to measles, diarrheal
diseases, malnutrition, hunger, etc.
• In the short term, we may have increased COVID-19 related morbidity and
mortality but it seems less likely as:
• The lockdown was not effective and regularly practiced, and in a large extend violated
• Its assume that a large number of people are already having an asymptomatic infection
• Young population (more than 67% under the age of 25) mostly experience mild diseases
with minimum mortality
• Exposure, particularly of the young population, to more infection may induce herd
immunity. However, the WHO has condemned the “dangerous” concept of herd immunity for
managing the COVID-19 pandemic*
*https://www.thehindu.com/sci-tech/science/aiming-to-achieve-herd-immunity-naturally-is-dangerous-who-warns/article31602074.ece
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13. Control option III
• Strengthening and expanding all intervention under OPTION I except
lockdown
Immediately end lockdown
• Majority of the 66% population engaged in informal employment may
resume their work, which may prevent increasing poverty
• Utilization of essential health services may return to pre COVID-19 era and
prevent excessive deaths due to measles, diarrheal diseases, malnutrition,
hunger, etc.
• Expected rapid increase in COVID-19 related morbidity and mortality
• Possibly less likely as the lockdown is not effective and regularly practiced, and in a
larger extend violated
• Young population (more than 67% under the age of 25) mostly experience mild diseases
with minimum mortality
• Though the context is different, we may need to deeply analyze and learn from the
experience of countries like Sweden
• Rapid exposure, particularly of the young population, to more infection may induced
herd immunity. However, the WHO has condemned the “dangerous” concept of herd
immunity for managing the COVID-19 pandemic*
• In long the term, likely to save more lives and reduce cumulative mortality due to
COVID-19 and other communicable diseases
*https://www.thehindu.com/sci-tech/science/aiming-to-achieve-herd-immunity-naturally-is-dangerous-who-warns/article31602074.ece
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14. Disclaimer
• This presentation expresses the
opinion of the presenter and does not
reflect the official stand of WHO and
MoPH
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