“We are asking ourselves if we could really handle a surge of patients.”
Preparing for COVID-19 in Kenya
Dr. Faye Evans is an anesthesiologist at Boston Children’s Hospital. As a Lifebox board member and member of Smile Train’s Medical Advisory Board, Dr. Evans has worked with anesthesia providers all over the world on safety and training programs. On March 30, 2020, Dr. Evans spoke with her long-time colleague and collaborator Dr. Susan Nabulindo, an anesthesiologist at the University of Nairobi and Kenyatta National Hospital in Nairobi, Kenya about the COVID-19 situation and specific concerns for the safety of anesthesia providers facing the pandemic in Kenya. Recorded on March 30, 2020. Below is a rough transcript of the interview.
Faye Evans: Hi Susane. This is Susane Nabulindo and she has been kind enough to let me interview her on the COVID situation in her home country. First of all if you could just state your name and where you are and how we know each other.
Susane Nabulindo: I am Dr. Susanne Nabulindo. I am a pediatric anesthesiologist at the University of Nairobi working at the Kenyatta National Hospital. I also offer critical care services in the hospital. I have worked with Faye probably for the last 6 years on many projects and also basically mainly on a fellowship of pediatric anesthesia in Kenya, which has picked up very well in our country and many other pediatric anesthesia in the country and region.
FE: Can you share with the folks who are listening where you are now and tell me a little bit about the COVID-19 situation in your region.
SN: Currently I am in Nairobi, that is where I work and where I live. That is the capital city of Kenya.
We recorded our first COVID positive case on 13th of March 2020. That is about two weeks ago—so from then the government, the Ministry of Health together with a task force of experts, have been following the situation and have been reporting on the cases increasing.
As for today, 30 of March, we have a total of 50 confirmed cases positive and they are all in isolation and being followed up. Contact tracing of all of these positive confirmed cases have also been traced and being followed up. It is important to note that up to today, most of our cases had been people who had traveled into the country, but today we have had the first case of probable community infections going on as reported by the Cabinet Secretary for Health in the brief for today. So, we are now getting into a new place for today that there are confirmed cases that there is community infection going on.
So far, they are still testing people—a week ago all travelers coming from outside the country had been blanket had to self-quarantine going home so the government put in place that everyone was to be quarantined in coming from outside of the country, where everybody was to be quarantined in specific places designated by the government. So we have people who came into the country so that testing of those particular people is going on in particular intervals depending on when they came in. So contacts for people who have been confirmed positive have also been followed up and put in isolation places and testing going on.
So testing is going on, not widespread yet. It is mainly for the people in quarantine and the contacts of the confirmed cases so far. We have been assured that depending on the situation that they are monitoring then they will spread the testing along on a wider range depending on what they are monitoring. But currently it is just the contacts of those quarantined and people coming in from the countries of concern.
FE: Of the 50 people who have contracted the disease, are they in hospital, do you know?
SN: All of them are basically isolated—so they are in various places where the government has said there is an isolation unit at one of the hospitals where most of the patients are. We had two patients in ICU who we are the only patient we have lost so far, he had been admitted in the ICU, so far the reports have been that most of the patients who have been tested positive are in the isolation unit and they are quite stable. That is the information we have.
FE: These patients, would they most likely come to Kenyatta or would they come to any of the hospitals?
SN: So far the Ministry of Health has been very categorical in communicating where these patients need to go, so Kenyatta National Hospital has an isolation unit which was built before—because of Ebola and cholera cases—and that was used as one of the isolation places. But for this COVID-19 isolation unit it was in our neighboring hospital Mbgathi County Hospital. It was where the bigger isolation unit was.
FE: How many beds are in the isolation unit, do you know?
SN: In the Kenyatta National Hospital, the isolation unit has 6 beds and in Mbgathi there were 11 beds, but they have been expanded because of the number of cases. So there are not so many.
Then there is also Kenyatta University Referral Hospital which is a big new hospital that when the epidemic came in they were just opening the hospital so that hospital has been designated a COVID hospital as we continue just getting patients and they have up to 350 beds which they are preparing as isolation beds for the start.
FE: When patients come to the hospital because they are sick, they would just be transferred to those hospitals if they were suspected of COVID?
SN: Since the public health education started quite early with the MOH people going out to educate people through radio, media, SMS through one of the big telecommunication, free SMS to people. There is a number that people are expected to call. People are discouraged from coming into the hospital. If you develop symptoms that are being described in the media, particular symptoms of febrile respiratory illness then you can call this number and not come to the hospital. You will be directed where to go. If you aren’t feeling well then there is an option of sending an ambulance to pick you instead of you walking into the hospital emergency room. So so far in the city of Nairobi this has been working well but in the periphery this has been lagging behind but as time passes the communication and the plans are being put down to the county levels and the periphery so there is a lot of public information going out for TV, radio, SMS to people’s phones through the Ministry of Health. The good thing is that phone use in Kenya is quite widespread so that people are able to get these messages.
FE: Are you doing much around social distancing?
SN: Yes, the social distancing advice has been going out since about when we had the first case. Initially it was just advising people to social distance and advising them on what social distancing is through the various channels. Then as the cases continued they went ahead and now starting putting measures in how many people can be carried in a public service vehicle and the public service vehicles were told to downgrade and only carry 60% of their capacity and they were asked to wash their hands and all public transport should have sanitizer and people should wash their hands before they get in. It has been a challenge with people not obeying, of course, but now now they have told supermarkets to put hand sanitizer in place so they are going to lengths to limit the number of people to go into supermarkets at any given time so even those who are queuing are told to spaces.
Slowly, slowly as time goes by measures are put in place for social distancing. Schools were closed immediately as soon as the first case was diagnosed so schools and universities were closed immediately so children are at home. People are encouraged to work at home so most people are working at home, only essential service people are allowed to go work.
FE: Sounds like you guys jumped on that really fast. We were much delayed.
SN: And then about four days ago there was the imposition of a 7 pm to 5 am curfew so everybody is supposed to be out of the public areas by 7 pm. Again we don’t know how this is supposed to work but then again this has been put in place very strictly so that employers have been told to send people home from 4 pm so that basically no public places are open at night so this has actually decreased the number of people going into restaurants, into clubs, so everybody is to be at home by 7 pm to 5 am, no movement apart from essential services. So the doctors have mainly been given special passes to move around with at night if you have to go to work at night.
FE: As an anesthesiologist in your country, what concerns do you have regarding COVID-19. Do you feel that you are at particular risk in your setting, at your hospital?
SN: Yes, as an anesthesiologist and probably talking about what we have been sharing in our anesthesia group is that people are very concerned. One because the fact that we have stopped elective surgeries by the way. The elective surgery started going down about two weeks ago and apart from private hospitals elective surgeries have been scaled down to very few hospitals are running elective surgeries and even very few are running elective surgeries and even those that are running elective surgeries, it is at small volumes.
The concern is that the anesthesiologists and even other doctors are still seeing patients. These are emergency cases, patients who are coming into the hospitals from the community so we might have a patient who is involved in a motor vehicle accident coming in; they are coming in from the community. Testing is not widespread so the concerns of having people who might have been exposed coming in who are positive coming in to surgery and you do not know because we are not testing this particular patient. There has been a struggle of trying to convince the administrators of the various hospitals that basically anesthesiologists, especially during procedures where we are having intubation, airway procedures, we need to have protection. Most of the administrators are not buying into that yet because people are still hanging onto the fact that most patients are not positive and it is only slowly, slowly that most hospitals are now starting to agree that now that we have confirmed community spread going on then if you are getting into these procedures that are high risk then probably you need to protect yourself. Whether people use it for protection depends on where they are working.
People have gone to the lengths of providing their own masks, purchasing N95 masks for their own use. That is not quite sustainable because as it is now in the various hospitals the anesthesiologists and the doctors in the front line are not being given PPE to use if the cases are not confirmed.
The other concern is the uncertainty and the fear of what is coming ahead with what people are watching is going on in the rest of the world. We are asking ourselves if we could really handle a surge of patients especially when it comes to if we were to receive a huge number of patients requiring critical care. Starting with the infrastructure and mainly also human resources, people who can actually take over which falls on anesthesia in our country. We are quite few so the anxiety is whether we are ready to handle that if we reach a point of we have to decide who gets a ventilator or not so those anxieties are what people are discussing now and causing a bit of anxiety. But specifically right now for us is personal protection in an environment where testing is not widespread and you are still seeing patients coming from a community where there is confirmed community spread going on.
FE: What do you think your hospital needs right now other than PPE?
SN: So what we talk about is that we are at the planning level and we are trying to use statistics from what we are seeing in the rest of the world. We fully assume that most of the patients we shall receive are basically who might not need critical care but are patients who are sick enough to be taken care in the hospital. We are talking about whether we have enough oxygen supply. Most hospitals depend on oxygen cylinders, they do not have their own oxygen plants. Just one hospital, the Kenyatta National Hospital, which has been taken as one of the hospitals that will take positive patients when they become many has its own oxygen plant but most of the hospitals depend on buying cylinders of oxygen so that might be one thing that might run down so we are thinking of probably having a backup like having oxygen concentrators. That means that we can make oxygen from the air as we go. Then we have questions of whether we have enough oxygen masks, just the usual ones.
FE: Because you guys normally reuse those between patients so that is a really good thing that has not come up in discussion, the oxygen face masks.
SN: So we know that most of the patients might have moderate disease so we need the masks to be with us. So discussions today with the rest of the anesthesiologists and hospitals is to try and interrogate how many masks do you have, where are we getting the supplies from, so we need to have a big supply of these which today I do not believe we have. Even in Kenyatta National Hospital where I am sometimes we have very few of those and sometimes you have them but you have the wrong size for the patients. Those are some of the basic things that we might require.
Then monitoring. Pulse oximeters, available in the OR are not usually available anywhere else in the hospitals apart from the ORs and the ICUs but if we have to make beds for patients out of these particular areas then we probably need more monitors and things like pulse oximeters because we know our main problem for these patients is oxygenation so maintaining oxygenation is one of the key things that we have to do if we have to make beds out of ICUs and out of ORs.
Then of course just the other supplies like IV fluids, feeds, and people are looking at that. And then lastly if we get into a situation of having a lot of critically ill patients who require ICU our number of ventilators will not be able to sustain that but the government has said they purchased ventilators and they are promising to purchase more but that is probably another area where we might need more support.
FE: What about sharing protocols and things like that so that we don’t re-invent the wheel? Clearly they will have to be adapted to the Kenyan context but I am curious.
SN: The personnel, trained personnel, again we are low on that. We have ICU trained nurses, again not so many, but a good number so we are trying to map out where these ICU nurses are.
Then we have the doctors so again the question of anesthesiologists. We are now about 200. Another group graduated just recently so we are about 200 anesthesiologists scattered all over the place. We have a few of our other colleagues in other specialties who do critical care, internal medicine, people who do pediatrics and now we have the medical officers as well. We have the medical officers working in the ICUs for a long time and then there are the clinical officers in anesthesia who might be helpful so that and the nurses.
So then the struggle has been that information has been very fragmented and people are taking so much information from social media so having a channel where you have information tailored for people who will take care of patients—protocols, information that has been authenticated, information on what has been successful and sharing it would be very, very important.
FE: I think, Susane, the amount of materials I hope that people will have places, at least healthcare workers, that CDC the WHO, as far as anesthesia specific resources, I am hoping the WFSA will have a lot and some national societies, ASA, AAGBI, and also the APSF. There is an article that I will share with you that has a bunch of really good resources and I think the key is just not to get overwhelmed by the resources and find a site that is relevant to you or ask your colleagues. So, as you face the COVID-19 outbreak in your country, what do you as Susane Nabulindo fear most?
SN: Yes, so, personally, the fear is basically the point at which you have a surge of patients and knowing how our health system is currently, my fear is that a lot of people might get infected and die out in the rural area without ever reaching hospital. And they might not even be counted as part of the statistics of the deaths from COVID-19. That is my fear in that much early even if we have a surge we will have a lot of people whom we might lose back in the rural areas because of the health system and the way it is right now.
FE: What gives you the most hope? What makes you think, ‘Hey, it’s going to be okay’?
SN: What gives me the most hope is that we probably have been lucky to be at the tail end of receiving this body so we are learning from others who have done it and the others who have done it probably the high-resourced societies. So if we basically take lessons from the high-resource settings who have been overwhelmed and they are telling us these are the few things that worked well if we put those things in place well then probably we can handle the situation when it comes to us.
So that is what gives me hope, that we have a bit of time to talk and plan and convince the population that doing some public health things might actually make the situation better for us. And, also the fact that the government, the Ministry of Health is taking this very seriously and putting measures in place as they receive the information is also something that gives me hope. That probably as we are learning from people as we see things and we should put measures in place and be able to dodge some bullets compared to if we were all in the dark and we are receiving this without any experience from anybody else.
FE: Thank you, thank you, thank you.