Strategies adopted by Ghana during first and second waves of COVID-19 in Ghana

Delia Akosua Bandoh^1,&, Magdalene Akos Odikro¹, Joseph Asamoah Frimpong¹, Keziah Laurencia Malm², Franklin Asiedu-Bekoe³, Ernest Kenu¹

 

¹Ghana Field Epidemiology and Laboratory Training Programme, University of Ghana School of Public Health, Legon Accra, Ghana, ²National Malaria Control Programme, Ghana Health Service, Accra, Ghana, ³Public health Directorate, Ghana Health Service, Accra

 

 

^&Corresponding author
Delia Akosua Bandoh, Ghana Field Epidemiology and Laboratory Training Programme, University of Ghana School of Public Health, Legon Accra, Ghana. deliabandoh@gmail.com

 

 

 

 

The novel coronavirus disease, caused by SARS-CoV-2 has resulted in over 127 million cases and 2.79 million deaths globally [1]. Currently, 233 countries, areas or territories have recorded cases around the world. Though developed countries were the most hit by COVID-19, Sub-Saharan Africa has had a fair share of the pandemic [2]. In Africa, over three million cases have been recorded with over 100,000 deaths [3].

 

On March 12, 2020, Ghana recorded its first two cases, both of which were imported. A year on, Ghana has recorded over 90,000 cases with over 700 deaths [4]. Throughout this pandemic, Ghana has been hit by two major waves. The first wave occurred between June and August 2020 whiles the second occurred between January and February 2021. The country adopted various strategies to mitigate the effect of the pandemic which included enhanced contact tracing and surveillance with the ultimate goal of breaking the chain of transmission.

 

This write-up describes the enhanced contact tracing and surveillance strategies the country implemented during the first and second wave of COVID-19 pandemic in Ghana.

 

Strategies adopted during the First wave in Ghana

 

The standard contact tracing algorithm for COVID-19 was adopted by the Ghana Health Service from WHO and CDC guidelines. This algorithm was used in training of all health workers and who were involved in responding to the pandemic Figure 1.

 

As the pandemic progressed, it was observed that a high proportion of the cases were asymptomatic or experiences mild symptoms. Thus, they either self-medicated or used home remedies whiles they continued with their usual duties, increasing the spread of the disease. There was a need to adopt another strategy to be able to achieve the country´s goal of breaking transmission. The enhanced surveillance strategy was then introduced with the aim of detecting all COVID-19 infections and ensuring immediate response to them. This strategy laid emphasis on active and reactive case detection. The active case detection approach was used to find cases among people who did not present at the health facility. All persons who travelled into Ghana from the 3rd of March from countries with more than 200 COVID-19 cases were traced through immigration data and tested. Positives were isolated, managed and their contacts followed up for the 14-day period as required by the health service. Again, all travellers who arrived in Ghana from 22 March 2020 were mandatorily quarantined for 14 days and tested [5]. During the 14 days, daily temperature checks and the COVID-19 symptoms dairy were administered. If a traveller tested negative by the 14 day, they were allowed to go home. Subsequently, all international borders were closed to human traffic to restrict movement of people in and out of the country. Emergencies, and humanitarian needs flights were however allowed in-country under regulated conditions.

 

The other enhanced surveillance approach adopted was community surveillance [6]. The method focused on immediate contacts of the case, family members and people within 1-2km radius of cluster of cases. Community surveillance also known as Enhanced contact tracing entailed taking the geocoordinates of the case and mapping a 1 - 2km radius around the case´s location. All households withing this radius were screened and tested for COVID-19 as part of steps for active case finding. To make this approach effective, a partial lockdown was imposed on the two major towns in Ghana which had recorded the highest proportion of positive cases. All security agencies in the country, were included to enforce restriction of movement in these places.

 

Field epidemiologists from the Ghana FELTP and staff of Ghana Health Service mapped out the location of all confirmed cases to give a sense of the community spread and also generate heat maps to identify hotspots at the community level and also conduct community spread risk assessment Figure 2.

 

After the partial lock down, some other approaches the country used were; ban on all social and religious gatherings, building up the capacity of other laboratories to test samples and increasing risk communication activities across the country.

 

As these surveillance strategies were being carried out, the country also developed a case management strategy for management of cases that were being recorded with facilities designated as major COVID-19 isolation and treatment centres in the capital. All regions were also encouraged to identify isolation centres and build case management teams [7]. Additionally rigorous contact tracing and testing of contacts and people showing symptoms was added. The approach was to ensure testing, isolation and treatment of cases in order to break the chain of transmission. Health education and compulsory use of face masks for the public were enforced by regulatory officers in addition to encouragement of use of hand sanitizers and frequent washing of hands. These efforts were geared towards ensuring that the pandemic was controlled in the country.

 

Successes from the first wave

 

Adaptation of these strategies in the first wave of COVID-19 in Ghana were marked by achievements including the following. Ghana gained global commendation for the approaches used in tackling the COVID-19 pandemic [2]. this made the country serve as a source of technical assistance to neighbouring countries.

 

Through the geocoding of cases, the country was able to determine risk zones. These zones became the main focus for implementation of control measures to break the chain of transmission. Secondly, about 50-60% of cases identified in the country was through enhanced surveillance approach. The approach made Ghana one of the countries with the highest number of COVID-19 tests done in Sub-Saharan Africa [8]. This was very useful given that 80-90% of the cases recorded in the country were asymptomatic and would not have been picked up by the standard contact tracing algorithm. Again, a large number of imported cases were identified and treated at the port of entry. This reduced the spread of the disease within the communities. Finally, adaptation of these approaches led to the significant decrease in the number of cases in the country till December 2020.

 

Contributory Factors that led to COVID-19 Second Wave in Ghana

 

As Ghana began recording a decline in recorded COVID-19 cases, some pitfalls in the response during the first phase accumulated and ultimately led the country to experiencing the second wave of infections.

 

One contributory factor was the poor coordination between sectors; many sectors which include health, border and immigration services, Police service and National security were working during the response. Each organization had its modus operandi and because it is not routine for these organizations to collaborate, poor coordination was observed between the sectors. Additionally, there was inadequate funds to support the deployment of field epidemiologists for response. The initial funds for deployment of field epidemiologists came from non-Governmental organizations therefore when the funding run out, deployed field epidemiologists had to be recalled. The incident Management system, activated from the beginning of the pandemic continued to meet and discuss these issues. However, due to limited funding, the issues still persisted.

 

Ghana also faced the challenge of inadequate workforce for contact tracing. The already inadequate workforce also dwindled as the remuneration being provided for contact training reduced. For the available contact tracing workforce, contact tracing became much more difficult to conduct due to stigmatization and loopholes within the system that allowed cases to slip through. Ghana was using SORMAS as the national database for data on COVID-19 cases, most of the data from the database were incompletely filled making it difficult to track cases and their contacts. Once the cases are reached, some of them also gave out incomplete phone numbers and addresses for their contacts further impeding the efforts of the contact tracing team. The country also experienced challenges in linking walk in cases to care. This was because the testing centers were operating separately and increasing as time went by (Both private and public facilities and laboratories were testing for COVID-19), however there was no clear roadmap for linkage of all the cases from these testing sites to care.

 

From the community level, as the outbreak progressed, people became complacent and no longer adhered to the preventive protocols. Wearing of masks became by choice and frequent handwashing at vantage points decreased. A study revealed that the compliance to face mask use had declined especially public transportation [9]. As people became complacent about mitigation measures, they also started flouting other rules of bans on social gatherings that had been instituted by the government. Unfortunately, the institutions responsible for enforcement of the bans and wearing of masks ie; national security and security forces also relaxed. The complacency heightened during the Christmas festivities which saw many people travelling from the capital city to outskirts and mingling freely with their families and friends and further propagating the spread of the infection. Additionally, there were election campaigns and voting during the period and adherence to COVID-19 prevention protocol were not optimal. Additionally, shortly after the new Delta variant, was reported among international travelers arriving in the country, community transmission of the Delta variant was reported.

 

National Response Strategies for second wave of COVID-19 infections in Ghana

 

Ghana started experiencing the second wave of COVID-19 infections around January 5th, 2021. At this point, schools and institutions had been opened and the country was operating as per normal times within the mist of COVID-19 (i.e.; no restrictions on movements, schools, institutions in session, Christmas and new year´s breaks just ended) Figure 3.

 

With the start of the second wave, response strategies had to be revisited and revamped to address the increasing infection rates. The country´s strategy for response to the second wave geared towards breaking the chain of transmission of COVID-19 using 14 days as incubation period. For the country to break the chain of transmission, experts recognized the need for mandatory facemask use and restricted movement and use of other COVID-19 preventive protocols.

 

Testing centers with the capacity to conduct genomic sequencing also initiated genomic sequencing activities to determine the circulating variants in the country. The variants that were detected in country included the UK, Delta and South Africa variants were detected in community transmissions [10-12].

 

In addition, specific strategies were put in place to guide the response; the first step was to map the case distribution with the past 14 days. The rigorous mapping entailed listing and describing all positive cases in the country in the last 14-days. The geo-location of all the cases were mapped and hotpots were categorized. This data was used for making decisions for the response Figure 4-5.

 

Secondly, interventions were to be targeted based on case load or hotspot classification as categorized by the CDC using the data from the case mapping [13]. In any area categorized as having elevated COVID-19 incidence and therefore substantial transmission (50-99 cases per 100,000 persons in past 7 days in orange on figure 4), contact tracing was conducted for cases per Ghana´s existing contact tracing guidelines [14] and community education campaigns were intensified in these areas.

 

In areas with elevated incidence and high transmission efficiency categorized as High transmission (≥ 100 cases per 100,000 population in the past 7 days in red on figures 2 and 3), enhanced contact tracing was conducted as per Ghana´s guidelines [6]. Additionally, there may be full or partial restriction of movement in affected areas, rigorous enforcement of preventive measures ie. Face covering, physical distancing, handwashing with soap under running water and intensification of community education campaigns in these areas.

 

The information on the hotspot areas identified per district were disaggregated to the district level for action. Further Investigations conducted by the districts showed that most had drinking bars where people congregated frequently. Together with consultation at the national level, activities of these drinking bars were suspended for a period of 14 days to aid the break in transmission. This was accompanied with rigorous contact tracing and testing within identified hotspot areas and enforcement of preventive measures. Community based surveillance volunteers were also engaged to be able to pick up suspected cases at the community level and report to the district level for action.

 

Thirdly, schools and institutions-based surveillance were enhanced. All schools were audited for adherence to COVID-19 protocols. Schools were then linked to trained public Health Rapid Response Team´s (PHRRT´s). The linkage was important for early detection and response to any focal COVID-19 outbreaks in schools. From January to March, 2020, a total of 948 cases were recorded across 180 schools in Ghana.

 

The strategy to contain spread within schools included the use of bubble movement amongst students (students were re-organized to ensure that same people shared classrooms, dormitories and dining tables in boarding schools thereby reducing the spread of infection). Additionally, where necessary, students were quarantined for 14 days and rigorous contact tracing, testing and follow up was conducted for detected cases.

 

Additionally, deliberation on integration of COVID-19 testing into the existing ILI surveillance system was initiated. An assessment of the ILI surveillance system was done with gaps and linkages between ILI and COVID–19 identified. Following this, a pilot integrated ILI/SARS-CoV-2 surveillance system was rolled out to ensure all samples from the ILI sentinel sites were tested for both ILI and COVID-19.

 

Lastly the final strategy employed for the second wave was risk communication and social mobilization. Public health campaigns were intensified both in the general public and targeted to settings based on need. The increase in risk communication helped to demystify misinformation and adherence fatigue amongst the general populace.

 

These combinations of strategies led to reduced infection rates and ultimately the decrease in recorded cases in the country. The steady decrease observed from February 28th, 2021 has been maintained and as at March 15th, 2021, Ghana´s recorded COVID-19 cases started to move in a significant downward trend.

 

Lessons learnt from COVID-19 waves in Ghana

 

- From the COVID -19 waves, some lessons can be learnt for the future. One lesson that comes out strongly is the need to adopt and change strategies in the face of changing situations.

 

- Also, prompt decisions need to be made in the face of pandemics to be able to save lives and keep others from harm.

 

- Other lessons learnt include the enforcing set protocols to the letter even when it seems the expected results have been achieved to an extent.

 

- We can also learn from these experiences the need for effective risk communication and continuous risk communication throughout the outbreak throughout the entire pandemic to ensure people understand and create awareness.

 

- Again, during easing of restrictions, measures need to be put in place to ensure restrictions are not completely thrown away.

 

 

Ghana has experienced two major waves of COVID-19 since the emergence of the pandemic. From using basic strategies such as contact tracing, the country adopted other strategies such as enhanced surveillance, mapping of risk zone and enforcing of protocols such as mandatory wearing of face masks. Adaptation of dynamic strategies based on the changing pandemic helped in reduction of the impact of COVID-19 on the country.

 

 

Figure 1: Algorithm for COVID-19 contact tracing in Ghana, 2020

Figure 2: Enhanced contact tracing sampled that tested positive, 2020

Figure 3: Active COVID-19 cases in Ghana by day, Aug 2020 - Mar 2021

Figure 4: COVID-19 Second Wave Case Map, January 25th to February 8th, 2021

Figure 5: COVID-19 Second Wave School and Institution Distribution, Case Map, January 25th to February 8th, 2021

 

 

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