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New COVID-19 regulations and public health safety: The critical issues

Buhari signs Petroleum Industry Bill into law

President Muhammadu Buhari, on Wednesday 27th January 2021 signed new Coronavirus (COVID-19) Health Protection Regulations 2021 as part of efforts to boost the COVID-19 response in the country. Medical experts including the Nigerian Medical Association (NMA) welcomed the development as it was expected to reduce the rate of spread in COVID-19 infections, which has maintained a steady rise since December 2020.

As at 28 January 2021, statistics from the NCDC shows that Coronavirus cases in Nigeria stood at 126, 160, deaths 1,543 and recovered persons 100,365.

This is not the first time Buhari would sign such laws and may not be the last unless the pandemic comes to an end. From every indication, the new regulations became necessary because the previous ones were not fully complied with by Nigerians. Indeed, many people including top government officials and religious leaders still doubt the existence of the disease.

But health officials said the new regulations, which took immediate effect, were given urgent consideration to safeguard the health and ensure the well-being of Nigerians, especially in the face of rising COVID-19 cases in the country.

The guidelines state that any person that contravened provisions of the regulations, upon conviction, risked a fine or a term of six months imprisonment or both in accordance with Section 5 of the Quarantine Act. Laws are good, but laws are made for human beings.

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A careful study of the new and old regulations showed no major difference. Rather, it could be said that the new regulations merely reinforces what has been in existence, namely- people should wear face masks in all public places, wash their hands with soap in running tap water, maintain social distancing, avoid crowded places and obey other COVID-19 protocols. Nothing new.

However, the new regulations if effectively observed would give a downward slope to a number of infected cases and death. But it would have been nice if the government added the recommendation of immune boosters and other preventive prophylaxis such as Vit D, Zinc, and Ivermectin. Furthermore, there is a need to plead with pharmaceutical shops not to over-price such preventive drugs and masks. If possible, such drugs should be made available in all local government primary health care clinics, doctors’ clinics, and hospitals.

What could have caused the spike?

Nigeria’s economy, hit hard by the coronavirus pandemic, contracted by more than 3 percent last year. A number of factors might have aided the spike. Last December, the president ordered the reopening of Nigeria’s borders, closed in August 2019 to cut down on illegal trade. The closure had helped to restrain human and vehicular movement. But that has been lifted in line with the African Continental Free Trade Agreement (ACFTA)

Secondly, an average of 28 of the nation’s 36 states have reported a higher number of new COVID-19 cases each week compared to the previous week since the beginning of December. Nearly half of the total cases recorded have been reported during this period.

Thirdly, most recorded cases continue to be seen in Lagos and FCT, which have among the best capacity for testing. Nonetheless, record levels of reported cases are observable state-wide. States such as Rivers, Kano, Kaduna, Katsina, Delta, Edo, Imo, and Enugu, for example, have experienced steep increases in exposure during the second wave, though their cumulative number of reported cases remain relatively low.

Fourth, mutations in the COVID-19 virus detected in Nigeria in December that make it significantly more transmissible raise prospects that the second wave could become even more dispersed. While the virulence of the new variants remains to be seen, it bears recalling that the second wave of the Spanish flu pandemic a century ago was more widespread and lethal in Africa (and other parts of the world) than the first.

Fifth, the surge may be particularly dangerous for public health systems in states that have recorded their highest number of weekly cases during the second wave and whose public health systems were starting with fewer resources before the pandemic. Even states with stronger health systems and those that are not yet experiencing surges during the second wave are still at risk of being overburdened as the virus spreads into rural or active conflict areas.

Implications on health and economy

The number of COVID-19 cases detected in the country in the past one month indicates that a second wave of the outbreak has begun, said Boss Mustapha, Secretary to the Government of the Federation and chairman of the Presidential Task Force on COVID-19. Mustapha stressed that the country is at risk of losing not only the gains from the hard work of the last nine months but also the lives of citizens.

“We are in a potentially difficult phase of the COVID-19 resurgence. Accessing the hope offered by the arrival of the vaccine is still some time ahead,” he said.

Health Minister Osagie Ehanire had earlier announced that the government would receive 20 million doses of a COVID-19 vaccine by January 2021.

The year 2020 saw COVID-19 infect over 2.7 million Africans and kill over 65,000. A surge of cases in the last quarter of last year, combined with the emergence of more contagious mutations, pose new challenges for Nigeria and the rest of the world this year.

What’s the way forward?

As expected by many, we are now observing an increase of COVID-19 cases in many places where the epidemic first emerged. Among the most affected countries in Europe, Italy, France, United Kingdom, Germany, and Spain experienced an initial outbreak in the number of cases around March 2020 followed by a profound decay in the number of cases after May 2020, peaking again in November 2020. Russia had its first wave in the epidemic in May 2020, and after a valley in the number of cases, it is experiencing a new increase in the number of cases in November 2020. The new peaks of COVID-19 confirmed cases are accompanied also by an increase in the number of deaths, suggesting that the new wave does not reflect better diagnostic strategies and/or increased resources only. Larger heterogeneous countries like the United States and Brazil, which globally lead the number of COVID-19 related deaths, seems to experience a mix between the still ongoing first wave and a probably second wave in certain local geographic regions.

One new feature of this new wave in the COVID-19 pandemic is the affected population age group. According to the European CDC, the mean age of infected individuals and hospitalization are lower in this second wave compared to January-May, 2020. One can hypothesize that older individuals are less exposed at this time and therefore still less affected by this new epidemic wave. On the other hand, it is particularly the fact that in the first wave of the disease, younger individuals were not found to be symptomatic as they seem to be now, and the new situation could be considered unexpected.

SARS-COV-2 has a large spectrum of disease and symptoms. It has been recognized that most infections are asymptomatic or oligosymptomatic. The severity of the disease is in general associated to underline health conditions, sex, and age. It is also known that although effective, the regular and neutralizing antibodies may decay fast enabling hosts to be re-infected by the same coronavirus in a short period of time. Although hard to document, re-infection by SARS-COV-2 may occur, with some anecdotal reports being published. The first confirmed case of SARS-COV-2 re-infection resulted in a less symptomatic infection in comparison to the first episode of infection, but subsequent reinfection cases may result in a more severe second infection.

In fact, when trying to develop a vaccine for severe acute respiratory syndrome it has been detected a phenomenon named antibody-dependent enhancement, which makes the response to the infection a more symptomatic disease. Therefore, it is conceivable that the new second wave of COVID-19 infections may represent many re-infection cases. The rationale for that would be that many younger individuals were infected during the first wave of the disease being misdiagnosed since the first infection was asymptomatic or oligosymptomatic. Although the duration of viral shedding may be higher among asymptomatic individuals, medical experts say up to 40% of asymptomatic individuals will never produce IgG compared to 12.9% of symptomatic cases. This is because the decay of regular IgG or neutralizing antibodies is fast in both symptomatic and asymptomatic persons. It is conceivable that some infected individuals in Nigeria will not develop protecting immunity or will need multiple infections to develop protection.

This possibility should not be hard to explore. Up to now, the negative predicted value of serologic tests is low, especially among asymptomatic individuals who will not produce antibodies in as many as 40% of the cases. The window period for SARS-COV-2 IgG production is of 6-12 days, and IgG will not last long among asymptomatic patients with a half-life of approximately 36 days. In this sense, it would be interesting to test these individuals with the acute disease using also an antibody-based assay since the re-exposure to the antigen could boost the past antibody response bringing back an old and more mature breath of IgG.

Suffice it to say, though useful, regulations alone would not stop the spread of the disease unless combined with the knowledge that could help in understanding the current status and predict the future of this new pandemic.

On a last note, rather than make stringent laws that would not be obeyed or obeyed in exception, the government should embark on public enlightenment/ awareness creation and campaign to convince Nigerians on the benefits of observing the covid-19 protocol. A visit to several rural communities shows that awareness is very low. The situation is not helped by religious preaching and misinformation against the pandemic. Even some state governors are not giving it the needed push. For instance, President Buhari at the initial stage of the outbreak did not wear a face mask and this gave the public a wrong signal. The political will was missing. The new resolve to curb the spread should therefore commence on awareness creation like the case of polio vaccination which was initially resisted by the people. Even the planned mass vaccination may not receive the needed public support as indicated by the recent statement from Islamic leaders.