Outbreak of SARS-CoV2 in a tertiary institution, Ghana, March 2020: Lessons learnt through early contact tracing

Charles Lwanga Noora^{1, &}, Mary Coleman², Abraham Anang², Ernest Kenu¹

 

¹Ghana Field Epidemiology and Laboratory Training Program, School of Public Health, University of Ghana, ²Nugochi Memorial Institute for medical Research, University of Ghana, Legon

 

 

^&Corresponding author
Charles Lwanga Noora, Ghana Field Epidemiology and Laboratory Training Program, School of Public Health, University of Ghana. nooralwanga@gmail.com

 

 

 

 

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by coronaviruses, specifically, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Coronavirus disease (COVID-19), caused by SARS-CoV-2 virus was first identified in Wuhan, China in December 2019 and has since spread to 222 other countries and territories [1,2] On 30 January 2020, the World Health Organization declared the disease a Public Health Emergency of International Concern [3] By 25th February 2021, COVID-19 had affected 112,209,815 and killed 2,490,776 worldwide [2].

 

COVID-19 can be transmitted from person to person through droplets of saliva or discharge from the nose when an infected person coughs, exhales, or sneezes. It is also transmitted by touching the surface of an infected object; then touching the eyes, nose, or mouth without properly washing your hands. The incubation period of the disease ranges from 1 to 14 days [2].

 

The best way to prevent and slow down transmission is informed about the COVID-19 virus, the disease it causes and how it spreads, protect yourself and others from infection by washing your hands or using an alcohol-based rub frequently and not touching your face.

 

As of March 2020, there were no specific vaccines or treatments for COVID-19. However, there were many ongoing clinical trials evaluating potential treatments. However, Ghana´s case management protocol at the time of the outbreak included holding on to all suspected or confirmed COVID-19 cases in reporting facilities, homes or treatment centers without referral [4]. Instead contact via phone call the National Ambulance Service following which a designated ambulance would be provided to transport the suspected or confirmed case from the holding facility or their home, to an appropriate treatment centre. A multi-disciplinary COVID-19 case management team was put in place to manage all confirmed cases of COVID-19 both symptomatic and asymptomatic following a develop treatment guidelines mainly using oral Hydroxychloroquine and azithromycin or Doxycycline [4].

 

In Ghana, the first COVID-19 confirmed cases were reported on 12 March 2020 [4]. Initially, cases were concentrated in the Accra, Kumasi and Takoradi metropolis but spread to other districts across the country. Data from the Ghana Health Service show that as at 22 February 2021, the COVID-19 case count for the country was 82,131 out of which 75,604 had recovered and 594 had died [5]. The test positivity rate nationwide was shown to be 9.3% [6].

 

On the morning of 13 March, about 9.00am, a 36-year-old female student who return from US presented at Nyaho Medical centre, a private health facility with history fever, cough, general weakness, severe headache, and runny nose. She was admitted to the emergency unit and suspected as a case of COVID 19. Her throat swab sample was taken and sent to Noguchi Memorial Institute for Medical Research (NMIMR) for SARS-CoV-2 testing. On 15 March, diagnosis of SARS-CoV-2 was confirmed by a PCR test. On 15 March, the Director of the Ghana Field Epidemiology and Laboratory Training Programme (GFELTP) was notify of a COVID-19 confirmed case by authorities of a tertiary institution. A team made of residents and alumni from the GFELTP was constituted to investigate the outbreak to determine the magnitude of the outbreak, conduct contact tracing and monitor contacts and institute control measures to stop the outbreak.

 

 

Outbreak Setting

 

The outbreak occurred in one of Ghana´s biggest Tertiary institutions with an estimated population of 60,000. The population of the institution includes students of different levels and programmes, teaching and non-teaching staff. Students attend lectures in enclosed classrooms and engage in outdoor and indoor games. Majority of students reside in student hotels where up to four students share a room and other infrastructures such as washrooms and toilets. Aside from classrooms and residences, students also interact at various banking halls, stores and supermarkets within the school environment. The investigation commenced on 18 March, involving an initial in-depth interview with the index case and subsequently listing and identifying all possible contacts of the case.

 

Study design

 

This was a descriptive epidemiological study of the outbreak of COVID-19 in a tertiary school within the first month of the COVID-19 pandemic in Ghana. strategies were employed to gather information from confirmed cases and contacts to inform containment and management measures. The investigation was conducted for a week commencing on 18 March 2020.

 

Data collection

 

A team of field epidemiologists was formed and discharged to conduct the outbreak investigation. The team engaged the authorities of the institution for first-hand information and interviewed the index case on travel history, clinical manifestation, contact with a COVID-19 case, places and persons visited to identify potential contacts and addresses of places and contacts. The interview was conducted using a semi-structured questionnaire. the data collected informed the listing of contacts who were subsequently contacted for follow-up.

 

Case definition

 

Suspected Case

 

A person presenting with Fever (>38°C) or a history of fever and symptoms of respiratory tract illness e.g. cough, difficulty in breathing AND a history of travel to or residence in a location reporting person to person transmission of COVID-19 during the last 14 days prior to symptom onset.

 

OR

 

A person with Fever (>38°C) or a history of fever and symptoms of respiratory tract illness e.g. cough, difficulty in breathing AND in the last 14 days before symptom onset, close contact with a person who is under investigation or confirmed for COVID-19.

 

OR

 

A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND in the absence of an alternative diagnosis that fully explains the clinical presentation.

 

Probable case

 

A suspect case for whom testing for the COVID-19 virus is inconclusive.

 

OR

 

A suspect case for whom testing could not be performed for any reason.

 

Confirmed case

 

A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.

 

Contact Tracing and Identification of cases

 

Tracing and identifying exposed contacts were done and line listed by a team of 17 Field Epidemiologists from the Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), the Ghana Health Service (GHS) and supported by the institution. The Team was made of four Medical Officers who were responsible for the general management of the case and all identified contacts, two nurses who monitored contacts using the symptoms dairy, three Laboratory Scientists responsible for sample collection, packaging and transport to testing laboratories and eight Public Health Officers who identified and listed all contacts of each case. Contact listing was done with the aid of the contact listing form where all the necessary details including age, sex, location, last day of contact with infected person were collected.

 

Contacts of the institution index case were traced and assessed for fever, signs, and symptoms of COVID-19. Contacts without symptoms were monitored for 14 days post last exposure to case by contact monitoring teams each made of Resident Epidemiologist. All identified contacts without any signs and symptoms of COVID-19 (suspected case) were quarantined in a designated Hall within the institution isolated, tested. All contacts who develop any signs or symptoms during the quarantine period was tested while all contacts completing the mandatory 14 days quarantine period without any sign and symptoms were all tested.

 

Twice Daily Monitoring and Follow up of Contacts

 

Resident Epidemiologists from the Ghana Field Epidemiology and Laboratory Training Programme conducted daily monitoring and following up visits on all contacts using a symptoms dairy. They reported monitoring findings both in hard copy forms, and real time reporting in SORMAS an electronic data collection and management tool for surveillance. SORMAS was installed on smart phones and data entered as monitoring on daily basis up till day 14 of the last contact. Upon completing the monitoring of each contact, data were immediately uploaded to a server. The SORMAS data and information is accessible by password to the Head of National Disease Surveillance Department, Director of GFELTP, Director Public Health, Director General of the Ghana Health Service. For each line listed contact, temperature, signs, and symptoms of COVID-19 are monitored 8 hourly (morning and evening) for 14 days starting from the last day of exposure. We maintained a backup manual reporting system throughout the period.

 

Laboratory investigations

 

Sample taking was usually done at the quarantine centre for any contact who developed signs and symptoms and also at the end of the mandatory quarantine period of 14 days. Trained laboratory personnel dressed in full personal protective equipment took nasal/throat swabs into sterile containers and sealed in zip lock bags. The laboratory personnel were assisted by contact tracers who had been trained to fill case base forms appropriately. Samples were sorted to match their corresponding Epid numbers (these are unique IDs generated using Country, Region, District and Year codes and serial sample numbers) on the case-base forms at close of each day. All samples taken from contacts of confirmed COVID 19 cases and suspected individuals were well packaged under aseptic conditions and transported to the Noguchi Memorial Institute for Medical Research, at the University of Ghana for testing. Samples were transported on appropriate transport media to the laboratory within a suitable duration after collection.

 

Case management

 

The index case was handed over to the COVID 19 case management team at the UGMC as soon as authorities of the institution received positive lab results. Upon assessment of case´s health condition and home condition, the case was manged at the UGMC.

 

Teams were assigned on Tuesday 17 March 2020 and contact follow up started on Wednesday 18 March 2020. There were issues with adherence to quarantine rules initially. Contacts were moved to Jean Nelson Hall on Saturday 21/03/2020 where each was allocated a room.

 

Samples were taken on Friday 27 March 2020. All 94 students, together with their lecturers tested negative and were discharged on Saturday 28 March 2020.

 

 

Meeting with Local Health Officials

 

The investigation team was informed that, following the country´s first confirmed cases on the 12 of March, and a subsequent presidential directive the institution had been closed effective Monday, 16 March 2020. All other students except the categories of possible contacts as listed via a telephone conversation earlier with the GFELTP Director were ask to go home. They included direct class mates of the case, roommates and Hall colleagues while the rest of the possible contact were to be listed after an interview with the case.

 

Source and magnitude of the Outbreak

 

There was one (1) confirmed case (index case), a female aged 36 years who survived after receiving treatment. This was an imported case who travelled into Ghana from the United States and presented a day after her return to a private medical centre. The total number of contacts identified and listed were 94 and they were exposed at various risk levels Table 1. The median age of contacts was 20 years (range 17 years to 74 years). The distribution of contacts by place: Intuitional contacts; 91, Class mates: 61, Hostel: 12, Institutional staff: 16 and Hospital Contacts: 5.

 

Active Case Search

 

Two suspected cases were captured in the active case search at the intuition´s hospital after records review. A 24-year-old male referred from Adenta polyclinic presented with a one-day history blood stained vomitus, nausea, joint pain, and difficulty in breathing. A 38-year-old male who presented at Madina Poly clinic on 14th March, with a recent travel history to Benin, a one-day history of fever, difficulty in breathing and abdominal pain. They both tested negative by PCR at NMIMR. There were no suspected cases through routine surveillance at the institution health facility.

 

Contact follow up

 

A total of 94 contact follow-ups for 21 identified contacts all tested negative at the end of the follow up period. About 10.6% (10/94 developed various symptom during the follow up period but received negative PCR result on all occasions.

 

Case Management

 

The only confirmed case had no co-morbid conditions: asthma, hypertension and diabetes. The case was managed with oral Azithromycin, Vitamin C and Zinc. All the contacts who were quarantined were prescribed Vitamin C and Zinc. Other supportive treatment such as sun exposure for Vitamin D, steam inhalation, liberal oral fluid intake, balanced diet and exercise were offered the case.

 

Implementation of control measures to reduce risk of transmission

 

All contacts were provided facemasks and they were to wear them each time a contact tracer or a medical staff visits them in their rooms.

 

We educated and ensured physical distancing for activities like clearing the waste, their duties typically require employees to work together, especially the cleaners keeping them in proximity to each other. All contacts, contact tracers and employees were provided adequate supply of hand sanitizers. Hand washing facilities were also provided at the centre while ensuring continuous supply of water to the contact on quarantine. We ensured cleaning was done only in the mornings in broad day light with cleaners wearing the appropriate PPEs, we ensure door handles, floors, rails, desks and tops were cleaned once a day. All other workers outside of the quarantine centre were expected to keep their own workspace clean. Temperature check of employees such as security personnel, cleaners, and drivers at entry points was instituted. Posters on COVID-protocols such us how to perform hand washing and wearing of face mask were placed at vantage areas.

 

Lessons learnt

 

Through the active case, contact tracing and implementation of various control and preventive interventions, the following lessons were learnt.

 

The affected institution had a robust surveillance system in place capable of early detection of diseases among the students. The robust surveillance system facilitated the early detection of the case and the implementation of measures to contain the disease and prevent its spread among the student populace.

 

The significance of prompt treatment or case management for both confirmed and suspected cases of COVID-19 was another lesson learnt. Through the case management protocols by the Ghana Health Service, both confirmed and suspected cases were managed separately by the medical team. This reduced the anxiety among the students and made them cooperate with the control measures.

 

Prompt Containment (quarantine and isolation) is a cardinal lesson that was learnt through managing this outbreak. Through the containment measures implemented, the chain of transmission was truncated and this prevented further cases of the disease among the students.

 

 

Following the confirmation of Ghana´s first cases of COVID-19 on 12 March 2020, this was the first confirmed institutional COVID-19 case. In this confined community of adults, which included students and staff, we showed that early surveillance and response after exposure to cases may limit COVID-19 transmission. Despite the prudent measures implemented to prevent importation of cases of COVID-19 in Ghana, we confirmed a case imported from US in a tertiary academic institution this provides further evidence that all the earlier cases were imported from outbreak countries. There were 94 contacts identified from one confirmed case based on the WHO and the Ghana Ministry of Health interim guidelines [7,8], this affirms earlier knowledge that contact diseases like Covid-19 at minimum, a single case may come in contact with at least 2 individuals and up to 500 contacts within 7 days. These study findings reflect similar findings conducted on COVID-19 in Ghana [9] and the UK where on average, 36 contacts were traced to a case even though these were purely household cases or imported cases and not school based. Similar to what has been reported previously [9-11], most of our contacts were asymptomatic. These occurrences had the potential to translate into community transmissions if prompt measures were not taken particularly in a tertiary academic institution, which a unique setting centred on direct person-to-person interactions between students and lecturers in lecture theatres, and administrative staff in their offices without any physical barrier. This environment has the potential to exacerbate the risk of infection transmission. Our investigation in the early stages of the COVID-19 outbreak determined the magnitude of the outbreak in the tertiary academic institution, traced and monitored contacts. We also instituted control measures to stop the outbreak. Similar approaches were adopted in China [11] and Germany [10] to manage COVID-19 outbreaks in small communities. Contact tracing is known to be highly effective for diseases that spread slowly by close contact (person to-person), and hence is used for many sexually transmitted infections and contact diseases like COVID-19 [9-10,12]. This strategy was well employed and help break the chain of transmission of the infection particularly in the initial stages of the COVID-19 where transmission rates all the world were very high with severe outcomes [9,12]. The effectiveness of the contact tracing in this investigation and the rapid but effective response in quarantine, daily monitoring, use of prophylaxis and closure of school may have contributed to breaking the chain of transmission.

 

 

This outbreak was due to an imported case from outside Ghana. The prompt response to this outbreak via quarantine of contacts and prophylactic treatment of contacts helped stop the focal outbreak and kept the outbreak to only one confirmed case with no fatality. There were no secondary cases as community transmission was zero. Majority of the contacts were males who were mostly class mates of the case.

 

Recommendations

 

• Authorities of the institution should ensure provision of adequate hand washing facilities at vantage points within the institution before its re opening

 

• Ensure strict adherence to COVID 19 protocols i.e., hand washing, wearing of nose mask and use of hand sanitizers at all times.

 

• Ensure temperature monitoring at all entry points for all persons

 

• Designate COVID focal persons with their contacts made available to all

 

Public Health Action Taken

 

• Health education of healthcare workers and the general public by GFELTP team to contacts and employees of the institution.

 

• Supervisory visits to all two institutional health facilities to ensure correct use of COVID case definition and protocols to generate quality data and reports.

 

 

The authors declare no competing interests.

 

 

CLN, MC, EK conducted the investigations, CLN drafted the manuscript, AA and EK reviewed the manuscript. All authors read and approved the final manuscript.

 

 

The authors wish to thank the GFELTP family for giving us the platform to be able to conduct the study and also we wish to thank the case and contacts of this study for their openness and cooperation during the investigation.

 

 

Table 1: Sex and Risk distribution of COVID-19 Contacts by risk level and sex, March 2020

 

 

1. WHO.Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. Geneva: WHO; 2020 February 28 [updated 2020 Mar 11; cited 2023 May 29]. 40 p.


2. World Health Organization.Weekly epidemiological update - 25 February 2021 [Internet]. Geneva: WHO; 2021 February 25 [cited: 2023 May 29].


3. WHO.Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. Geneva: WHO; 2020 January 30 [cited 2023 May 29].


4. Ministry of Health Ghana.First confirmed COVID-19 cases in Ghana 12 Mar 2020 [Internet]. Accra, Ghana: MoH; 2020 March 12 [cited 2023 April 15].


5. Ghana Health Service.Covid-19 Outbreak in Ghana as at 22 February 2021 [Internet]. Ghana: GHS; 2021 February 22 [cited 2023 April 26].


6. Ghana Health Service.Ghana´s Outbreak Response Management Updates-January 2021 [Internet]. Ghana: GHS: ; 2021 January [cited 2023 April 26]. 2 p.


7. Ghana Ministry of Health.Provisional Standard Treatment Guidelines for Novel Coronavirus Infection COVID - 19: Guidelines for Ghana [Internet]. Accra, Ghana: MoH; 2020 [cited: 2023 April 26]. 35 p.


8. World Health Organization.Clinical management of COVID-19: interim guidance, 27 May 2020 [Internet]. World Health Organization: Geneva; 2020 May 27 [2023 April 26]. 62 p. Report No.: WHO/2019-nCoV/clinical/2020.5


9. A Odikro M, Kenu E, L Malm K, Asiedu-Bekoe F, L Noora C, L Noora C, Frimpong J, Calys-Tagoe B, A Koram K.Epidemiology of COVID-19 outbreak in Ghana, 2020 . GMJ [Internet]. 2020 Dec 31 [2023 May 29];54(4s):5-15. https://doi.org/10.4314/gmj.v54i4s.3 PubMed | Google Scholar


10. Böhmer MM, Buchholz U, Corman VM, Hoch M, Katz K, Marosevic DV, Böhm S, Woudenberg T, Ackermann N, Konrad R, Eberle U, Treis B, Dangel A, Bengs K, Fingerle V, Berger A, Hörmansdorfer S, Ippisch S, Wicklein B, Grahl A, Pörtner K, Muller N, Zeitlmann N, Boender TS, Cai W, Reich A, an der Heiden M, Rexroth U, Hamouda O, Schneider J, Veith T, Mühlemann B, Wölfel R, Antwerpen M, Walter M, Protzer U, Liebl B, Haas W, Sing A, Drosten C, Zapf A. Investigation of a COVID-19 outbreak in Germany resulting from a single travel-associated primary case: a case series . The Lancet Infectious Diseases [Internet]. 2020 May 15 [cited 2023 Jan 27];20(8):920-8. https://doi.org/1016/S1473-3099(20)30314-5 PubMed | Google Scholar


11. Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A, Taylor J, Page LC, Kimball A, Arons M, Munanga A, Stone N, Jernigan JA, Reddy SC, Lewis J, Cohen SA, Jerome KR, Duchin JS, Neme S.Outbreak investigation of covid-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington . JAMA Intern Med [Internet]. 2020 May 21 [cited 2023 Jan 27];180(8):1101-1105. https://doi.org/10.1001/jamainternmed.2020.2233 PubMed | Google Scholar


12. World Health Organization.Modes of transmission of virus causing COVID-19: implications for IPC Precaution Recommendations: Scientific Brief, 27 March 2020 [Internet]. World Health Organization; 2020 Mar 27 [cited 2023 Feb 6]. 3 p. Report No.: WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.1 Google Scholar