“We will be on the front line where it’s risky.”
Preparing for COVID-19 in Zimbabwe
Faye Evans: Hi guys, thanks for coming. Thanks for letting me interview you, I really appreciate it. Do I have permission to record you? Just to make sure that’s OK with both of you?
Danai Marange and Tsitsi Chimhundu: Yes, that’s fine.
Faye: I’m Faye Evans. I’m a member of the global council at Lifebox. If the two of you could introduce yourselves and maybe just say a brief blurb about how we know each other? That would be fantastic. Tsitsi why don’t you go first?
Tsitsi: OK, I’m Tsitsi Chimhundu from Zimbabwe pediatric anesthetists and I’m working in Zimbabwe Harare Children’s Hospital. I’ve known Faye for a while; we met during the pediatric anesthesia fellowship in Nairobi and then when I came as an SPA fellow and we’ve been collaborating since and become good friends.
Faye: Yep! And Danai, I’m afraid of what you’re going to say but go for it!
Danai: Hello I’m Danai Marange. I’m a pediatric anesthetist working at Harare Children’s Hospital in Zimbabwe. I’ve known Faye for a couple of months now, through Tsitsi.
Faye: And where are you guys currently located in Zimbabwe?
Danai and Tsitsi: In Harare.
Faye: And are there currently any COVID-19 cases in Harare?
Danai: Yes. Currently we’ve got 6 cases that have been proven to be COVID positive. One has since died so that makes a total of 7 cases.
Faye: And is this in all of Zimbabwe or just in Harare?
Danai: All of Zimbabwe.
Faye: OK. And do you think this number is accurate, because is there currently testing available or not?
Tsitsi: There’s testing available but I think the numbers are probably not accurate because there are a lot of people in the community with symptoms, but we’re not sure whether they’re being all tested or if the testing is keeping up to scratch with all the probable cases. I’m not sure but I don’t think it’s accurate.
Faye: How do they think that the newscaster who passed away, how do they think he contracted it? Where had he been?
Tsitsi: He was in New York.
Faye: Ah, got it. And did he die in Zimbabwe?
Faye: So he came back to Zimbabwe. Did he know he was sick when he came back?
Tsitsi: Well the story goes when he came back he didn’t know he was sick. He had a little bit of fever when he arrived at the airport but I think for some reason he just slipped through the cracks and then some days later he started developing symptoms, went to see a doctor and he was supposed to get into self quarantine but he continued to be up and about and because of that he had contacts.
Faye: So tell me a little bit about the hospital where the two of you work. Is it an adult and pediatric hospital or just adults? How big is it?
Danai: It’s a pediatric hospital but it’s not really a standalone hospital in the sense that it’s a part of Harare Central Hospitals also they’ve got an adult wing and maternity wing as well as the children’s hospital. In terms of bed capacity I think, Tsitsi, you know better about the children’s hospital.
Tsitsi: The adult hospital is about 1000 beds and the children’s if I’m not mistaken has 3 or 4 hundred, about 400.
Faye: And are there any COVID positive patients in the hospital currently?
Tsitsi: No, not confirmed ones.
Faye: OK. And what’s been going on in Zimbabwe at the country level and also at your hospital to prepare for COVID? Or anything about what is going on?
Tsitsi: Danai’s been heavily involved with that, I think I’ll leave her to answer that particular one.
Danai: OK, so what has been happening at a country level, there have been a number of committees that have been formed. Most of these committees were only formed after the death of the newscaster. Prior to that, the major center that was being prepared for COVID patients is Wilkins Infectious Disease Hospital. If I’m not mistaken the bed capacity that had been allocated for COVID patients is 40 plus something. They didn’t have any ICU facilities and they are still being [**inaudible**] as we speak, so at the time we had the one death, we didn’t have any ICU facilities at this center. That’s with Wilkins. So after that, a number of committees have been formed but as of now, there hasn’t yet been any official public hospital that has been allocated to deal with COVID patients. So right now the only place that patients can go to at the moment is Wilkins Infectious Disease Hospital. Although discussions are underway to see if we can at least convert one of the public hospitals into a COVID center. There’s also some talk that is going on, I can’t say 100% confirmed, to also have private institutions that will be managing COVID patients.
Faye: So currently, for an example, if a patient who was COVID positive came to your hospital, they wouldn’t be able to be admitted if they knew that they were COVID positive?
Tsitsi: No. What I would actually add is that at Wilkins Infectious Disease Hospital they don’t have any intensivists working with them or ICU nurses so if there was an actual patient who needed critical care, in terms of personnel and also the equipment, there are no dedicated people who work there.
Faye: Do they have ventilators?
Tsitsi: No they don’t have. Danai: As of today, they have a few ventilators that have now arrived but they are still to be set up in the allocated spaces for the ventilators as [**inaudible**]
Faye: How widespread is the availability of oxygen, oxygen concentrators? Are those widely available?
Danai: No they are not. As for Wilkins, it actually didn’t have any piped oxygen and they were relying on cylinders and they were running out with the last patient who was admitted there. So oxygen is an issue and availability is also an issue at the moment.
Faye: Do they have the ability with monitoring to be able to measure saturations, like with Lifebox pulse oximeters and things like that, or no?
Danai: I won’t be able to answer that positively. What I know is that when the patient who deceased was at Wilkins Hospital they were measuring the saturations but I’m not sure if it was the Lifebox or something else.
Faye: Right. Is the government at a government level doing anything at all to prepare the public to try to prevent the pandemic from spreading in Zimbabwe, such as social distancing, shutting down businesses, anything at all?
Tsitsi: There has been a lot of public information going out in terms of social distancing and avoiding crowds, so initially when the outbreak started they started saying you can’t have gatherings of more than 100 and as we have more cases they decreased it down to 50. As of today we are officially in a lockdown and only people who are involved in social services such as us as doctors and those involved in food services and grocery stores are allowed to move around. The police and soldiers are actually on the roads, manning the roads, making sure people are not moving around. So we are in a lockdown for 21 days and they are hoping that will somehow curb the spread of the disease. The borders have been also shut down. I think those are the major things, the main principles of the lockdown.
Faye: Many people out there often think of folks who provide aneesthesia as the doctors or non-physician providers who put patients to sleep for surgery, but we know in your setting your responsibilities can be much broader than that. Danai, can you share what other roles you play other than just in the operating theatre and putting patients to sleep? Do you have any roles in critical care or other things?
Danai: In answer to that, we don’t have any intensivists so besides helping to provide anesthesia, we also have to manage all patients who require high care and will require intensive care support. So we have those major roles, we also double up as intensivists.
Faye: So as an anesthesiologist, especially in your setting, what are your concerns right now regarding COVID? Do you feel like you’re at risk for COVID, being exposed?
Tsitsi: Oh yes, that’s a major concern. It’s a big fear and I think what’s happened in the last week or so is even our registrars who work in the department have had so much fear that they’re missing days at work, they’re calling in sick, because I think our exposure is much higher. And if it comes to the fact that if patients need to be admitted in the ICU and we need to take care of them, we are not many anesthetists in the country. We feel like we will be overwhelmed, we will be on the front line where it’s risky. Even if I were to get sick, I’m not sure whether the system would be able to give me the support that I’d need. That’s the worry.
Faye: Right. Danai, anything to add to that?
Danai: Yeah, the other other issues that have been affecting us is that people are worried about their families as well. For most people they don’t stay in big houses whereby you can self isolate yourself when you come back from work. So that has been a major concern. Then also because there is inadequate testing, so even in our interactions in the hospital right now we say we don’t have patients who are COVID positive but the reality is we don’t know. And also as things are, even for us the healthcare workers, the other fear is if I get infected what happens to me? The isolation center is not yet really ready, so if I get sick what happens?
Faye: Yeah, if you’re not testing then it’s hard to know who goes to the isolation center. You could be exposed and not even realise it.
Faye: It sounds like just from a practical standpoint in the ORs in your setting, at your hospital, it sounds like you do not have PPE, correct? Personal protective equipment. Do you have N95 masks, or any type of mask that you can wear to protect yourself from COVID?
Tsitsi: The N95 masks are not in every single hospital. In our setting you have to work at the two major hospitals in Harare, which is Harare Hospital and Parirenyatwa Hospital, and I only think the masks became available round about Friday and Monday if I’m not mistaken but all along they were not widely available. In addition, we also have to go into the private institutions and there it brings in another facet where there’s not enough PPE. So I think our exposure is greater because we hop from institution to institution.
Faye: Have the surgeons reduced their elective cases because of all this?
Faye: That’s good. A question I asked recently – in our ORs, we have the ability that the air circulates, so during an intubation if the patient was to aerosolize some of the virus, there’s a filtration system in our operating rooms where they’re doing a constant exchange of air so within 30 minutes there would be no virus in the air because of the circulation. I know that does not happen there. Do you guys have negative pressure rooms, or do they exist in your setting? No, I didn’t think so. So the other question is when you hook a patient to a ventilator, do you always put on a viral filter? Do you know what I’m talking about?
Tsitsi: Yeah we do, but not always. It depends on whether they are there – would you agree Danai? Because sometimes they’re not there.
Faye: So those are not readily available?
Tsitsi: They are there but I wouldn’t say they are there every single time. What do you think, Danai?
[Danai has lost connection]
Faye: She’ll come back. So the filters do protect… What we are all of a sudden discussing is let’s say you anesthetised a patient who was COVID positive and let’s say they exhaled and you did not have a filter in place, the virus could get into the machine. And then, the fact that you don’t have a scavenging system, do you?
Tsitsi: No. Yeah, that’s the other issue. We were trying to do a simulation last week. Now that there’s the whole COVID thing we’ve been emphasising to have a filter every single time that we’re intubating any patient because we’re treating them as positive; we don’t know. We don’t have scavenging systems.
Faye: Great. So as long as I think you just need to change that filter every single case, it’s super important. What about the other place you have to be really careful about is end-tidal CO2 sampling. Do you have end-tidal CO2 or no?
Tsitsi: I would say in most of the theatres, there are some that don’t have end-tidal.
Faye: So you just need to make sure that that end-tidal CO2 sample is after the filter. Or, the other thing you can do, is take a stopcock and cut up some of the filter, put it in the stopcock so that that sample line – gas that gets through it – gets filtered as well. Make sense?
Tsitsi: Yeah, we generally put it after the filter.
Faye: OK good, so that should be fine. What would you say as far as what do you need mostly right now for your hospital and your system?
Tsitsi: What we need right now, first of all, we need to start with a definite protocol on how to handle a COVID patient in terms of if they need critical care, if they’re coming to the OR or even if they are to present at hospital, how do we handle them? Because right now we don’t have a clear protocol of how to handle such a patient. Number two, we need training on the donning and doffing of PPE. Even if the PPE is available, we have not had any formal training on how to put on and take off the PPE. I think that’s the major thing that we need to start with before we even wait for any equipment. And then we need the actual PPE. Right now, what I can say is yes we have cancelled a lot of elective cases but even for the emergency cases, people are looking for any excuse not to go to work because there’s a fear of exposure, there’s not enough PPE. So if that was to become available that would help. The N95 mask, like I was saying, is not readily available. Also, equipment to use in terms of ventilators, critical care consumables and resources. What I would say lastly is we need a clear pathway in terms of which hospital would be designated as a COVID hospital. Obviously we can’t have COVID patients at every single hospital. In Harare, for example, we have two major government hospitals, and we were asking them, because there are not enough anesthetists and intensivists to go to the Infectious Disease Hospital can they convert one of those hospitals to become a COVID center so that we avoid contamination between the two centers and it’s clear we get ready. Right now we feel like we’re just waiting for the bomb to drop; we’re not ready at all. Those are the things that I think we would need to start with. Because right now we feel very exposed.
Faye: Do you think some of those protocols will be developed in country or would that be something that the global community could try to help you with? I know that PPE you’ll need help from the global community for sure.
Tsitsi: Yeah. Having a framework to work with from the global community would be excellent but some of the nitty-gritty’s would need to be sorted out at country level, because we’ve got different problems and probably the mistake we made is we thought that it would come from above to us but we’ve realised we just need to start working on a protocol as a department and doing some drills on how to protect ourselves. Because clearly the protection might not come from up there. We need to be proactive and get it going.
Faye: Lifebox, Nicole Star, is starting to put together a whole document about the ‘Do’s and Don’ts of PPE’, which I think will be invaluable, specifically geared towards an LMIC setting, not our setting. To be honest guys we’re facing very similar issues, in that we don’t have enough equipment, we’re panicked, we don’t have the protocols. They’re definitely going into place but they’re not black and white and things are changing daily. So it’s not like we have all the answers, we’re learning and I think folks are generally interested in sharing all that they can. The wider issue I will tell you to think about as the government in practice, the idea of having one hospital to care for these patients is going to be challenging because you don’t always know that they’re positive. So while you can try to minimise the amount of COVID positive patients that are in other facilities, you need to remember that children, for example, get exposed and you don’t even know they’re positive because their symptoms can be quite mild but yet they can be shedding virus. So I think it’s an interesting idea to limit and try to isolate like that, but in practicality it’s not going to be quite like that.
Tsitsi: So do you think, let’s say we’ve got COVID patients in each hospital, we should have a wing for them?
Faye: I don’t know. You’ve just got to make sure that patients who come in who have symptoms, obviously you know who those are and you separate them but recognise that there are going to be patients who are asymptomatic. Especially children, which affects us so much. And I think that’s what’s given the angst to us in our hospital is that we probably won’t see a ton of really sick patients but we’re going to be exposed as healthcare workers because they’re going to be positive and we’re not going to know they’re positive and then we’re going to get sick and then we’re going to go home and spread it to people. So I think that’s another concern that we have.
I’m curious – Danai told me this as you were off then – but I’d be curious to hear as you face this outbreak in your country what do you fear most?
[Danai is back online]
Tsitsi: I fear also infecting my family.
Faye: Yeah. Danai said the same thing. What gives you the most hope as we go forward in the unknown? We all are in a period of unknown.
Tsitsi: I think the fact that at least in children it’s mild, so at least my kids will probably be fine!
Faye: Danai, do you have anything different?
Danai: For me, when I just look at what this thing has done in the first world countries where they are better resourced and with the PPE and everything. I know that as people and as the medical profession, we are doing as much as we can but at the end of the day doctors have been infected with full protection so my hope is in God to protect me.
Faye: Yeah. It’s amazing to hear from you guys because you’re the best of the best in your country. You’re educated and you’re in the most well resourced setting. And then I think about the non-physician providers out at the district hospital. I don’t even know where to start for them. If the patients really get out there, it could really devastate things quite badly.
Faye: But I don’t even know how you prevent that. Because it’s not like Ebola where it’s a small area you could isolate. It’s everywhere.
Tsitsi: It is, yeah.
Danai: It’s everywhere.