Lessons learnt and recommendations
Timely screening, testing and diagnosis: There is a need to ensure that all health workers have the ability to identify COVID-19 suspects, as per the MoH guidelines. The first case was first admitted at a health facility on 15th July 2020 before she was referred to another health facility on 20th July 2020, without being identified as a COVID-19 suspect. Given the symptoms she presented with, the district response team should have been notified on the first day of admission and relevant precautions like isolation, referral and COVID-19 tests done according to the MoH COVID-19 guidelines [13]. This would help in early diagnosis, limit the number of case contacts and also enable early initiation of treatment. The second case was initially admitted into a well-equipped and stuffed private hospital located within the capital city and less than 2 kilometres from Mulago National Referral Hospital. However, this patient was still not suspected to have been a potential COVID-19 case despite the typical symptoms and age risk. This could partly be due to inadequate awareness or a low index of suspicion among healthcare providers.
Strengthening the testing services by ensuring increased laboratory coverage is required. At the time the first two deaths, the country had only 6 accredited COVID-19 testing laboratories. However, as of 30th July 2020, the number has been scaled up to 18 laboratories [6]. The MoH should work towards ensuring that atleast every district or region has a laboratory that is able to offer COVID-19 testing services. In the first case, the patient was referred from the Namisindwa district to a health facility in Mbale district. Despite the presence of Mbale regional referral hospital in the district, the COVID-19 tests were only able to be done in the Tororo and Kampala districts. Delayed testing, as noted in the first case, risks further spread of the disease by unknowing contacts. Priority and routine testing, preferably with short-turnaround-time (STAT) tests, is essential for real-time patient management and infection control. When other less infectious forms of pneumonia are present, and respiratory isolate resources are scarce there is need for the doctors to have a high index of suspicion especially among the front line workers working in high-risk locations of the country as they come into direct contact with patients [14].
Furthermore, results from studies done in various countries show that asymptomatic persons are playing a significant role in the transmission of COVID-19. This underlines the need for a change of approach from symptom-based screening, especially among staff at healthcare facilities. If no routine screening is done among HCW and support staff, we may fail to detect infectious cases leading to disastrous results [15,16].
Strengthening of health center capacity: The need to ensure that the health workers are able to provide services as per the ministry of health structure is noted. The first case was admitted in a health center II, for over four days, which is not meant for inpatient care. According to Uganda's healthcare system, each district should have a General Hospital, and referral level Health Centre IVs at the county level. Each Health Center IV supervises a number of Health Centre IIIs at a sub-county level, which often have maternal health services in addition to ambulatory care. Below the Health Centre IIIs are dispensaries called Health Centre IIs, at a parish level, that offer outpatient services. At the community level, there are Village Health Teams who provide the day-to-day referral of patients from the community [17]. However, the lack of transportation could partly explain the observed delays in referral, which calls for prioritisation of ambulance services, especially in the high-risk districts.
Improving Healthcare workers' capacity: There is a need to ensure that health facility staff have, and are able to use the necessary information regarding COVID-19 prevention and also ensuring that all staff, including support staff, have the needed personal protective equipment (PPE). The first case was a support staff at a health center II, so there is a possibility that she contracted the virus while at work. The infection and subsequent death of front-line healthcare workers (except infectious disease physicians) maybe because they received inadequate training for Infection Prevention and Control (IPC), leaving them with a lack of knowledge of IPC for respiratory borne infectious diseases [18]. After initiation of emergency responses, healthcare workers and hospital support staff may not have dedicated enough time for systematic training and practice. Professional/ supportive supervision and guidance, as well as monitoring mechanisms, should be improved in both Government and Private facilities nationwide to avoid amplifying the risk of infection for healthcare workers [19]. Recommendations such as traffic control bundling and Systems Engineering Initiative for Patient Safety (SEIPS) model in which patients move along routes other than those taken by all HCWs and support staff should be considered [20,21].
Community awareness: A need to strengthen and continue community sensitisation and awareness about the dangers of COVID-19 has also been noted. In the first case, the government officials had to be involved in order to stop the locals from attending the burial [22]. This shows that the community still needs to be sensitised to ensure social and behaviour change. Furthermore, most of the locals that had contact with the deceased deserted their homes for fear of being quarantined [22]. This risks further spread of the disease. The MoH needs to continue awareness about the public health significance of quarantine and ensure that the services and conditions in the quarantine centers are also improved.
Since Uganda is now in the stage of the epidemic that is characterised by community transmission of the virus, the postponement of school terms, the cancellation of mass gathering activities and other measures aimed at reducing the movement of people is still required as the quest for solutions goes on the control [23]. As lockdowns and physical distancing measures are eased, case detection, proactive surveillance, and contact tracing with isolation will be required to prevent a dramatic resurgence of COVID-19 cases [24,25,26]. In addition, the region-specific epidemiologic trend of Covid-19 in Namisindwa District and other high-risk districts needs to be investigated in order to prevent large scale community transmission in these areas [27,28].