Covid-19 Challenge: Repurposing community health strategy key

Kenya in mid-June is anticipating a surge in community transmission of COVID-19 in affected counties. The Chief Administrative Secretary (CAS) for Health, Dr. Rashid Aman, on the 10th of June 20120, acknowledged this situation stating, “due to our rising numbers of Covid-19 cases, it is increasingly becoming unattainable to isolate the patients in our health facilities for management and care.” In order to reduce pressure on healthcare isolation facilities in which the occupied COVID-19 capacity is already at 100%, the bulk of the patients can be managed at home provided proper laid down procedures are followed.

According to the available data, 78% of cases admitted in hospitals are either asymptomatic or mildly symptomatic, thus qualifying for homecare. A home-based care protocol has been developed by the Ministry of Health (MOH) to provide a solution in the management of the increasing numbers and the anticipated surge of Covid-19 infections. The national coverage of active community health units (CHUs), the delivery unit for home-based care, is at 67% with 82% of these CHUs lacking immediate supervisors.

This gap, amongst others, must be addressed in all COVID-19 affected counties. Current MOH policy on community engagement is that in the event there is surge of cases, CHVs can be trained and equipped to support active case finding in their CHUs and linked to COVID-19 isolation and treatment facilities. They can also be linked to sub-county rapid response surveillance teams (RRTs) and conduct daily monitoring and weekly reporting on progress of cases under self-isolation in households. This policy was restated by the CAS, but in the home based care protocols, the key activity of monitoring and reporting is left to the cases and household contacts themselves. Ambiguity in the policy on household monitoring and reporting will create implementation confusion if not harmonized across relevant protocols.

Community response strategies in counties with proven community transmission will be key to containing and stopping the spread of COVID-19. These strategies include 1) integrating COVID-19 prevention into the implementation of on-going community health strategy (CHS) activities, 2) activation and review of supportive community CHS structures to include Nyumba Kumi representation, 3) implementation of home-based care for self-isolated cases and their household contacts, 4) establishment and management of temporary community COVID-19 care centers to cater for those eligible but household status is not feasible, and 5) implementation of community-based targeted testing and surveillance amongst high risk groups and households.

In order to implement these strategies effectively, it will be essential to repurpose CHS structures and operations. County-wide, key repurposed activities include 1) accelerating training and equipping of CHS resource persons in COVID-19 prevention in the whole county, 2) mobilizing CHS technical resource persons at county and sub-county levels to undertake their defined roles as provided for in the minimum standards guidance, 3) activation and review of sub-county community structures to include Nyumba Kumi representatives as key partners, 4) establishing sub-county RRTs, 5) expanding CHVs role to include daily monitoring and reporting of cases and contacts, and, in specific settings like informal settlements, 6) operating temporary community care centers for quarantine of close contacts under the oversight of local Nyumba Kumi teams to monitor and ensure adherence to containment measures.

In order to enhance control measures in CHUs and other hotspots in the community experiencing surge in cases, additional repurposed targeted activities include: 1) equipping sub- county RRTs with point-of-care RT-PCR-based Xpert Xpress testing using portable machines that have ability for a fast turnaround of results in 45 minutes. CHVs assist the RRTs implement targeted house-to-house sample collection and may be deployed to conduct the testing when the need is very high.

This approach will provide a more timely identification of individuals who test positive, tracing of their contacts and minimize cases of individuals lost to follow-up. CHVs will also offer appropriate counseling, facilitate and participate in assessment of affected households to determine eligibility for home-based care, community-based care or facility care, 2) conduct of testing of asymptomatic frontline healthcare workers to provide a proxy indicator of the levels of transmission in the community and monitoring of the effects of containment measures.