Gaps and recommendations on the management of the coronavirus disease 2019 (COVID-19) in the Zimbabwean quarantine centres during the first wave (March - October 2020)

Richard Makurumidze^1,2,3,4,&, Mutsa Mhangara¹, Justice Mudavanhu¹, Grant Murewanhema^1,5

 

¹Zimbabwe College of Public Health Physicians, Harare, Zimbabwe, ²Family Medicine, Global and Public Health Unit, Department of Primary Health Care Sciences, University of Zimbabwe, Faculty of Medicine and Health Sciences, ³Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium, ⁴Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium, ⁵Obstetrics and Gynaecology Unit, Department of Primary Health Care Sciences, University of Zimbabwe, Faculty of Medicine and Health Sciences

 

 

^&Corresponding author
Richard Makurumidze, Family Medicine, Global and Public Health Unit, Department of Primary Health Care Sciences, University of Zimbabwe, Faculty of Medicine and Health Sciences, Harare, Zimbabwe. richardmakurumidze@yahoo.com

 

 

 

 

Introduction

 

The first human cases of coronavirus disease 2019 (COVID-19) were first reported in Wuhan City, China, in December 2019 [1]. The virus then spread to the rest of the world through inter-continental movement of people. To prevent the returnees (returning residents and other international travellers) coming to Zimbabwe from spreading the virus, the country established quarantine centres. By the end of May 2020, there were more than 35 quarantine centres dotted across the country. Quarantine was compulsory for all returnees [2]. The quarantine period was for 21 days, with COVID-19 testing performed on the first, eighth and 21st days, according to the national guidelines. Those who test positive were referred for treatment at designated isolation centres while those who test negative on the first, eighth and 21st were discharged at the end of the quarantine period. There was flexibility for those who test negative on the 8th day to be discharged and complete the 21 days follow-up at home [3].

 

Zimbabwe reported its first case of COVID-19 on the 21st of March 2020 [4]. Since then, the cases gradually increased, and by the 25th of May 2020, the country had 56 cases. Of the 56, 31 were imported while the remaining were local transmissions [5]. Between the 26th of May 2020 and the 12th of June 2020, slightly over a two-week period, there was a huge surge of cases to 343 [6]. The cases increased by 287 (513%) from 56, and of the 287, more than 95% were detected from quarantine centres while the remainder were either local transmissions or contacts of known cases. More than 95% of the quarantine centre cases were from South Africa while Mozambique, Botswana and a few other countries contributed the remainder [7]. There was a debate on whether the returnees were acquiring the COVID-19 infection in the quarantine centres or were already infected when they left the countries they were coming from.

 

There was a possibility that the returnees being diagnosed with COVID-19 in the quarantine centres were infected before departing their countries of origin since the pandemic had affected almost all the countries globally. However, this might not have been the case. Nearly all the returnees who end up in the quarantine centres pass through the formal repatriation process and border control measures. Before departure, at ports of entry and before entry into quarantine centres, basic symptoms screening and temperature checks are performed. Suspected cases are supposed to be identified, isolated and managed during those processes before they proceed further. Having said that, we cannot rule out the possibility of a few asymptomatic cases finding their way into quarantine centres and being the source of onward transmission. There is evidence showing transmission of COVID-19 from asymptomatic cases [8,9]. Hence, there is a possibility of some of the returnees getting COVID-19 infection in the quarantine centres. The source of infection being a few infected individuals who would have been missed through the screening processes before admission into the centres or the asymptomatic cases. We, therefore, conducted research to understand the conditions in the quarantine centres and provided recommendations to address some of the issues.

 

Methods

 

We conducted a desk review on published literature to understand the conditions in the quarantine centres. We performed an unstructured search in Google between May 2020 and July 2020 for media stories/reports on the living conditions in the Zimbabwean quarantine centres. On top of that, we performed a quick search in Google Scholar and PubMed for published local scientific articles on the topic. We also looked for official reports from the government and other stakeholders on the conditions in the quarantine centres. We extracted the data from the sources and summarised it thematically. Recommendations were formulated accordingly.

 

 

We found 13 media stories/reports [10-21] and three [22-25] reports from the government and other stakeholders which reported on the conditions in the Zimbabwe quarantine centres. There were no local peer-reviewed or rigorous scientific studies on the topic. The findings are summarised under the following themes:

 

Living conditions in quarantine centres

 

Some of the quarantine centres were over-crowded with poor living conditions. They lacked basic social amenities, ablution facilities and a consistent supply of running water. In some quarantine centres, returnees were sharing sleeping and dining rooms, ablution facilities and social amenities. Some returnees were staying beyond the stipulated 21 days in scenarios were one of the returnees test positive; the rationale for the extension being that the other returnees are now being treated as contacts of the positive case(s) [11,14,16, 21-23].

 

COVID -19 testing

 

The returnees in the quarantine centres were not being tested timely according to the recommended guidelines. Some were being asked to pay for the cost of the COVID-19 test which the majority could not afford. For those who were tested, there were delays in receiving the results, especially those with negative results [10,22-24].

 

Routine medical care, follow-up and monitoring

 

There was a lack of regular follow-up and monitoring of returnees by the Ministry of Health and Child care (MoHCC). Reports of MOHCC staff only surfacing if there is a positive returnee to be picked for treatment and isolation were made. A death was reported in one of the quarantine centres and the cause of death was concluded to be due to other underlying medical conditions and not COVID-19 related [15,23].

 

Personal protective equipment

 

There were poor infection prevention and control measures within the quarantine centres. There was lack of standard operating procedures, personal protective equipment (masks, gloves and sanitisers) and other necessary sundries to promote a hygienic environment both for returnees and staff. The situation was further worsened by the poor living conditions in the centres highlighted above [22,23].

 

Staffing, Supervision and security

 

Most of the quarantine centres were understaffed. In some quarantine centres, returnees took the lead in performing their day-to-day leaving duties, which include cleaning, cooking and dishing of food. There were reports of returnees indulging in sexual activities [20,23].

 

Monitoring, Evaluation and Data Collection Systems

 

The data collection system in most of the quarantine centres was paper based. This resulted in challenges in longitudinal tracking of returnees in terms of testing schedule, results, symptom screen and time in quarantine. There was duplication of information which was being collected by ministries and government departments that were involved in providing services in the quarantine centres [24].

 

The findings show that the returnees were at increased risk of getting COVID-19 infection in the quarantine centres. The sharing of rooms and other amenities together with the poor living conditions are against the social distancing requirements hence increasing the risk of COVID-19 transmission. The returnees are supposed to be tested on days 1, 8 and 21 before discharge [3]. The purpose of regular testing especially on days 1 and 8 is to identify and isolate those with ongoing infection to minimise spread to others.

 

The reported delay in receiving the COVID-19 results after testing has been mainly due to backlog caused by limited testing capacity at the testing laboratories and poor filing which led to the mixing of results from different provinces [13,14,19,24,24]. The delay in receiving results led to prolonged stay in the quarantine centres hence increasing the exposure and risk of contracting COVID-19. The MoHCC testing algorithm initially recommended the use of a rapid diagnostic antibody test for all returnees as the initial screening test on day 1 [25]. However, this is not recommended, considering the poor performance of the rapid antibody tests in detecting early infection [26].

 

Regular follow-up and monitoring of signs and symptoms, including fever, is key in identifying returnees who might develop COVID-19. The reported death in one of the quarantine centres could have been prevented by the provision of regular screening and follow-up medical services. The under-staffing in the quarantine centres led to gaps in services provision, proper supervision, monitoring and security. This was made worse by the poor coordination of several government ministries responsible for managing quarantine centres. The laxity of security resulted in some returnees escaping from the quarantine centres [27]. Those who escape pose a serious risk of propagating community transmission. The under-staffing also resulted in returnees failing to be tested on time, delays in receiving results or discharge and mixing of cohorts.

 

Studies have shown quarantining of suspected cases, contacts and high-risk subgroups including returnees from countries with ongoing community transmission as an effective and proven public health intervention to reduce the spread of COVID-19 at the same time reducing mortality and morbidity [28]. However, the use of evidence, empathy and respect for fundamental human rights should guide the implementation of the initiative [29]. To address the highlighted gaps and challenges, we recommended the following:

 

Living conditions in quarantine centres

 

The living conditions in the quarantine centres should be improved. Efforts should be made to house each returnee in his/her room without sharing ablution facilities and other social amenities. If this cannot be achieved the returnees can be accommodated in cohorts based on the same baseline signs and symptoms, diagnostic tests results, date of entering the quarantine centre or any other parameter that puts returnees at the same risk of harbouring COVID-19 [30]. Efforts should be made for each returnee to be served food in their room, but in situations where this cannot be done, social distancing should be observed. Disinfection of shared ablution, social and dining facilities should be done regularly. Staying in quarantine can be a stressful moment for returnees and where possible measures (internet, counselling and other entertainment activities) should be put in place to minimise the psychological complications.

 

COVID -19 testing

 

The testing of returnees in quarantine centres should be prioritised and the schedule of testing on days 1, 8 and 21 followed sincerely to minimise the risk of transmission. The efforts to decentralise COVID-19 testing should continue especially through the use of the Gene Xpert technology. Each quarantine centre should have its designated testing centre to avoid delays in testing and mixing of results. Efficient systems to feedback to returnees both negative and positive results should be established and prioritised. The testing of returnees should be primarily PCR based. However, as their performance improves, rapid antibody tests can be used to identify those who might have already been infected by COVID-19 from the countries of origin [29]. Pooled COVID-19 PCR testing for each quarantine centre should be considered to overcome the testing limitations. Pooled-sample PCR screening could save resources in settings where they are limited [30].

 

Routine medical care, follow-up and monitoring

 

MoHCC should provide healthcare workers to conduct regular symptom and fever screening for the returnees. Returnees with other medical conditions should be identified, isolated and managed accordingly. Returnees due for COVID-19 testing should be identified timely and specimens collected for testing. Returnees due for discharge should be identified on time and allowed to go home without further delay.

 

Personal protective equipment

 

Returnees and workers working in quarantine centres should be provided with personal protective equipment (masks, gloves, sanitisers, face shields, gowns) regularly depending on the risk of getting infected.

 

Staffing, training and capacity building

 

The government and supporting partners should move with speed to address the staff shortages in most quarantines to improve service delivery. Some efforts have been made in the area of staffing, training and capacity building. Further training and capacity building of staff on various elements of service delivery in the centres should be prioritised. However, considering the practical nature of the required skills and competencies, capacity building should be done via on-the-job training, support, supervision and mentoring. Mobile multi-disciplinary teams with experts from all the ministries and members from key professional bodies like the Zimbabwe College of Public Health Physicians should be established to support the capacity-building activities.

 

Supervision and security

 

There is a need for coordination and creation of a management team for every quarantine centre with members derived from government ministries involved in the handling of returnees, i.e. the MoHCC, Ministry of Foreign Affairs and International Relations, Ministry of Home Affairs, Ministry of National Housing and Public Works, Ministries of Education among others. Every quarantine centre should have an Accounting Officer to coordinate service delivery and day-to-day issues, including security. The move to withhold travel documents for returnees in quarantine centres might help in preventing escaping [31].

 

Guidelines for managing COVID-19 in quarantine centres

 

The guidelines on the management of COVID-19 in institutionalised facilities, including quarantine centres developed with support from the Zimbabwe College of Public Health Physicians should be finalised, launched and disseminated [3]. The process should be fast-tracked so that these much-needed guidelines are brought to use. Other government ministries involved in the handling of returnees should also be encouraged to start the process of developing their focus areas guidelines. In the long run, all the separate guidelines should be consolidated into a single multi-disciplinary and multi-sectoral guideline.

 

Funding and resource mobilisation

 

The government should continue to mobilise resources and increase the funding allocation to quarantine centres. To leave this responsibility merely to the government might be a huge task for them, considering the economic challenges the country is facing. Development partners, corporates and other stakeholders should come in and continue to support the government. The government should be flexible and consider allowing the adoption of some of the quarantine centres by development partners, non-governmental organisations and other donors. If the government and supporting stakeholders fail to raise the required resources needed to sustain these quarantine centres, they will be left with no option except to close them. This should, however, be the last resort considering the difficulties and dangers of home quarantine/isolation in our settings.

 

Monitoring, Evaluation and Data Collection Systems

 

The government should develop and implement an electronic integrated and linked data collection system for the management and monitoring of returnees in quarantine centres. Such a system will minimise duplication of data collection considering the number of government ministries and departments involved in the provision of services in the centres. The system will also enable easy tracking of medical management of returnees, i.e. testing schedule, results, symptom screen, date of discharge, and comorbidities, among other vital aspects. The system can be expanded to include the management of the following issues rooms check-in/out, meals, utensils and staff shifts. Monitoring and evaluation teams, which include members from external stakeholders like the Zimbabwe College of Public Health Physicians should be established to provide support and supervision visits.

 

Our review had some strengths, the most notable being that it was mainly based on personal stories of quarantine lived experiences. We also had data from a government survey and reports from independent non-governmental organisations that were involved in monitoring events in quarantine centres. However, our review had limitations, the most significant being that it was based on low-quality evidence, namely organisational reports and media stories. There were no well-structured local studies on quarantine centres at the time of the review. Proper studies may not have been possible due to how sensitive and political the issue of quarantine centres was at the time. On top of that, evidence on COVID-19 interventions was rapidly evolving. Even though the review was based on low-quality data, the multiple sources we used aided in the triangulation of findings. More well-structured studies are thus needed to better understand the situation in quarantine centres.

 

 

From our findings, there are chances that some of the returnees were getting COVID-19 infection in the quarantine centres. If the situation in quarantine centres is not addressed, it has the potential of initiating community transmission. The government and other stakeholders should prioritise the implementation of the suggested recommendations.

 

 

The authors declare no competing interests.

 

 

RM did the initial draft of the manuscript. All the other authors (MM, JM and GM) contributed and approved the final version of the paper.

 

 

1. WHO. Pneumonia of unknown cause - China [Internet] . World Health Organization; 05 January 2020 [cited 2023 May 2].


2. ZimFact. FACTSHEET: Zimbabwe COVID-19 isolation and quarantine facilities [Internet]. ZimFact; 06 May 2020 [cited 2023 May 02].


3. Government of Zimbabwe. Draft Integrated Guidelines for the Management of Individuals in Institutional Quarantine for the Prevention of SARS-CoV-2 (COVID-19) Zimbabwe. Harare, Zimbabwe: Government of Zimbabwe; 2020.


4. Ministry of Health and Child Care (MoHCC). Situation Report COVID-19, Zimbabwe - 02 April 2020 [Internet]. Harare, Zimbabwe: Ministry of Health and Child Care; 2020 [cited 2023 May 2. Download 03042020 Issue No 13 Zimbabwe COVID-19 Sitrep shared.pdf.


5. Ministry of Health and Child Care (MoHCC). Situation Reports COVID-19, Zimbabwe -25 May 2020 [Internet]. Harare, Zimbabwe: Ministry of Health and Child Care; 2020 [cited 2023 May 2]. Download 25-May-2020-COVID-19-Update.pdf.


6. Ministry of Health and Child Care (MoHCC). Situation Report COVID-19, Zimbabwe -12 June 2020 [Internet]. Harare, Zimbabwe: Ministry of Health and Child Care; 2020 [cited2023 May 2]. Download 12-June-2020-COVID-19-Highlights.pdf.


7. Ministry of Health and Child Care (MoHCC). Situation Reports COVID-19, Zimbabwe -11 June 2020 [Internet]. Harare, Zimbabwe: Ministry of Health and Child Care; 2020 [cited2023 May 2]. Download 11-June-2020-COVID-19-Highlights 1.pdf.


8. Pang J, Wang MX, Ang IYH, Tan SHX, Lewis RF, Chen JIP, Gutierrez RA, Gwee SXW, Chua PEY, Yang Q, Ng XY, Yap RKS, Tan HY, Teo YY, Tan CC, Cook AR, Yap JCH, Hsu LY. Potential Rapid Diagnostics, Vaccine and Therapeutics for 2019 Novel Coronavirus (2019-nCoV): A Systematic Review. JCM [Internet]. 2020 Feb 26 [cited 2023 May 2];9(3):623. https://doi.org/10.3390/jcm9030623 PubMed | Google Scholar


9. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, Taylor J, Spicer K, Bardossy AC, Oakley LP, Tanwar S, Dyal JW, Harney J, Chisty Z, Bell JM, Methner M, Paul P, Carlson CM, McLaughlin HP, Thornburg N, Tong S, Tamin A, Tao Y, Uehara A, Harcourt J, Clark S, Brostrom-Smith C, Page LC, Kay M, Lewis J, Montgomery P, Stone ND, Clark TA, Honein MA, Duchin JS, Jernigan JA. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med [Internet]. 2020 May 28 [cited 2023 May 2];382(22):2081-90. https://doi.org/10.1056/NEJMoa2008457 Google Scholar


10. A. Vinga. Quarantined Citizens Stage Demo Over Self-Funded US$65 Covid-19 Test . New Zimbabwe[Internet]. 2020 May 23 [cited 2023 May 2]:[about 9 paragraphs].


11. Madziwa M. How Zim Quarantine Centres Have Become Drivers of COVID-19 Infections. HealthTimes[Internet]. 2020 May 31 [cited 2023 May 3]:[about 18 paragraphs].


12. Phyllis Mbanje. More returnees test positive for Covid-19 . NewsDay Zimbabwe[Internet]. 2020 May 29 [cited 2023 May 3]:[about 17 paragraphs].


13. Madziwa M. My Nightmare in Quarantine [Internet]. NewsdzeZimbabwe; 2020 June 3 [cited 2023 May 3].


14. Plessis C Du. Covid-19 quarantine centres a misery for returning Zimbabweans. The Daily Maverick[Internet]. 2020 May 26 [cited 2023 May 3]:[about 25 paragraphs].


15. Midlands Bureau. Returnee dies in quarantine. The Herald[Internet]. 2020 May 19 [cited 2023 May 3]:[about 16 paragraphs].


16. Covid Prisoner. Open letter to the Minister of Health from Quarantine. HealthTimes[Internet]. 2020 June 14 [cited 2023 May 3]:[about 20 paragraphs].


17. Gwarisa M. COVID-19: Zim Quarantine Centers Now New COVID-19 Hotspots. HealthTimes [Internet]. 2020 May 26 [cited 2023 May 3]:[about 7 paragraphs].


18. Ndlovu R. Zimbabwe Tightens Security at Isolation Centers After 118 Escape [Internet]. Bloomberg; 2020 May 27 [cited 2023 May 3].


19. E Mushava. Inside the chaos at isolation centres. The Standard[Internet]. 2020 May 31 [cited 2023 May 3]:[about 7 paragraphs].


20. ZTN News. Covid-19: Zim returnees demand condoms [Internet]. ZTN; 2020 April 23 [cited 2023 May 3].


21. Bulawayo24 News. UN condemns Zim Covid-19 centres [Internet]. Bulawayo24 News; 2020 Jun 12 [cited 2020 Jun 13].


22. Zimbabwe Association of Doctors for Human Rights. 6th COVID-19 Monitoring and Advocacy Report: 2020 June 4 [Internet]. Zimbabwe: Zimbabwe Association of Doctors for Human Rights; 2020 Jun 4 [cited 2023 May 3]:[about 3 pages].


23. CARE International; Plan International; Dan Church Aid; Action Against Hunger; Africa Ahead; Nutrition Action Zimbabwe; Mercy Corps. COVID-19 Quarantine Centres Assessment Report: An assessment of the COVID-19 situation in quarantine centres of Zimbabwe in the following provinces: Bulawayo, Manicaland, Masvingo, Mashonaland Central, Matabeleland North, Matabaleland South, and Midlands [Internet]. Zimbabwe: Food Security Cluster; 2020 Jul[cited 2023 May 11] p. 17. This assessment was conducted with support from the Zimbabwe Disaster Rapid Response Mechanism project funded by European Union's Civil Protection and Humanitarian Aid Operations Department.


24. Women Coalition of Zimbabwe (WCOZ). Zimbabwe Lockdown: Day 60 - WCoZ Covid-19 Situation Report [Internet]. Kubatana: Harare, Zimbabwe; 28 May 2020 [cited 2023 May 3].


25. Mahomva A.(Secretary of Health and Child Care, Ministry. of Health and Child Care, Harare, Zimbabwe). Letter to: All PMDs, All CEOs, All City Health Directors, Private Hospitals. 2020 April 14. 2 leaves. Letter describing the strategy to increase active screening for COVID-19 in Zimbabwe.


26. Sethuraman N, Jeremiah SS, Ryo A. Interpreting Diagnostic Tests for SARS-CoV-2. JAMA [Internet]. 2020 May 6[cited 2023 May 3];323(22):2249-51. http://doi.org/10.1001/jama.2020.8259 Google Scholar


27. Jason B, Nyasha C. African nations fail to find coronavirus quarantine escapees. The Guardian [Internet]. International Edition. 2020 May 31[cited 2023 May 15].


28. Nussbaumer-Streit, B., V. Mayr, A.I. Dobrescu, A. Chapman, E. Persad, I. Klerings, G. Wagner, U. Siebert, C. Christof, C. Zachariah, and G. Gartlehner. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane database Syst Rev [Internet]. 2020 Apr 8 [cited 2023 May3];4:CD013574. https://doi.org/10.1002/14651858.CD013574 Google Scholar


29. Makurumidze R. Empathy and use of evidence in handling travellers coming from COVID-19 high-risk countries. Pan Afr Med J [Internet]. 2020 Jun 3 [cited 2023 May 3]; 35(2):60. https://doi.org/10.11604/pamj.supp.2020.35.2.23859 Google Scholar


30. Yelin I, Aharony N, Tamar ES, Argoetti A, Messer E, Berenbaum D, Shafran E, Kuzli A, Gandali N, Shkedi O, Hashimshony T, Mandel-Gutfreund Y, Halberthal M, Geffen Y, Szwarcwort-Cohen M, Kishony R. Evaluation of COVID-19 RT-qPCR Test in Multi sample Pools . Clinical Infectious Diseases [Internet]. 2020 May 02 [cited 2023 May 3];71(16):2073-8. https://doi.org/10.1093/cid/ciaa531 Google Scholar


31. Kitsepile N. Zimbabwe seizes returnees´ passports to deter escape from quarantine. The East African [Internet]. 2020 Jun 10[cited 2023 May 15].