Covid-19: Fourth wave still caught Kenya flat-footed, experts say

Long before President Uhuru Kenyatta and his entourage of political leaders arrived in Western Kenya in early June to mark Madaraka Day, medical officials in Kisumu County saw disaster brewing as coronavirus infections spiked.

Four months later, Kenya’s health system is beginning to breathe a sigh of relief as the average positivity rate -- a number that has been used to measure the percentage of people who test positive for the Covid-19 virus from a sample size of daily tests -- for Monday and Tuesday dropped to 4.4 percent, and 4.5 percent respectively, the lowest it has been in close to 17 weeks since the onset of the fourth wave.

In the context of Covid-19, the World Health Organization (WHO) advises that a country can only consider relaxing some public health and social measures such as curfews and banning public gatherings when the positivity rate is lower than five per cent for at least two weeks. As of September 22, about 246,956 people have tested positive for the disease, which has also killed 5,008. The country’s positivity rate is 4.5 percent.

Positivity rate

“Last time it [positivity rate] was below 5 percent was May 30, towards the end of the third wave,” Tweeted Dr Ahmed Kalebi, a pathologist who has been keeping tabs on the fluctuations of Covid-19 in Kenya.

As more and more people are tested, the focus shifts to the positivity rate -- how many of those tested are actually infected.

A modelling forecast from the Kenya Medical Research Institute (Kemri) in June warned of an imminent fourth wave with attendant risks of health service demand exceeding capacity. Ideally, modelling forecasts should be used to inform preparedness by both public and private sectors. In the first three waves, the government reacted quickly. But the public has felt some pandemic fatigue. And the economy and social life, in general, have been negatively affected by lockdowns.

The big concern was how Kenya would fare this time around. Yet, despite early warnings, experts across the public and private health sector argue that the country was still flat-footed in its response to stop the spread of the disease.

So how could a virus, which started in a small cluster of patients in a different county gain dominance in another? Well, the answer, according to health pundits lies in contact tracing or lack thereof.

For Dr Richard Ayah, a health systems and policy expert, battling coronavirus has to be both preventive and curative if the pressure on the country’s hospitals is to reduce.

“Most of the time, the second year of an epidemic or a pandemic is more lethal compared to the first. This is because people have relaxed the preventive measures they would take due to fatigue and a false belief in coping,” explained Dr Ayah.

“Delta came and it took us time to know the level of its severity because we are still not doing enough sequencing, which is a key guide on how to handle the disease. We are basically riding the wave.”

Contact tracing

When looking at the policy document by WHO on how to relax some public health and social measures, one thing is heavily emphasised: Contact tracing. The UN health agency stresses the need for a country to not only strive to lower the positivity rate, but also have a strong public health surveillance system (commonly referred to as contact tracing) able to detect and manage the cases and their contacts and identify a resurgence of cases. This is something most health experts interviewed for this article unanimously agreed is missing.

According to the experts, lack of contact tracing has been one of the major hurdles to proper infection control and spread of Covid-19. Contact tracing is the process of attempting to identify people who have recently been in contact with someone diagnosed with an infectious disease, in order to treat or quarantine them.

And if contact tracing is not revived and sustained, the experts argue, hospitals, both public and private, across the country will continue running out of oxygen supply and bed capacity as Covid-19 cases and hospitalisations continue to soar.

In Kisumu, it started with the identification of the Delta variant in four travellers who had come from India and settled in the lake region. From health experts' perspective, how those four cases would be handled would determine if the lethal and highly transmissible variant would move past Western Kenya.

Though data on infections and deaths is spotty, in June, more than 23 per cent of the people tested for the virus in Kisumu were positive — more than double the national rate. By July and August, big private hospitals in the city were so overwhelmed by the number of patients that they had to ship out many to other facilities.

As the virus seemingly came under control in Western Kenya, the trajectory was shifting to Kiambu and its neighbouring counties. When the situation became dire, the Health ministry acknowledged that the current fourth wave is mainly driven by the lethal and more transmissible Delta variant that has infected swathes of people who remain unvaccinated. Soon, the Delta variant completely replaced Beta (first identified in South Africa) to become the dominant variant of Covid-19 in the country, just like across the continent.

An article published in August in The Conversation Africa, by doctors from the Aga Khan University Hospital said the country was grappling with the Covid-19 Delta variant, which began in counties in the western part of the country, and had now threatened Nairobi and counties that surround it like Kiambu.

A document in our possession on the analysis of samples taken from patients at the Tigoni Covid Centre, Kiambu County, and analysed by Kemri, shows that seven of 15 samples collected between July 20 and 23 from Kiambu County tested positive for the Delta variant (B.1.617.2).

Whole-genome sequencing was done by the Kemri Wellcome Trust Programme (KWTRP) on July 30. Whole-genome sequencing is a laboratory procedure that determines whether a virus has mutated or not and provides vital information to scientists and policymakers to decide how to contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes Covid-19.

“This report provides evidence of the circulation of Delta (B.1.617.2) variant of concern in Kiambu county. The recovered Delta variant genome sequences fell into two major distinct clusters,” notes the exclusive document seen by the Nation.

With the crowd gathering (super spreader events) held on Madaraka Day in Kisumu County, cases began spiking, hospital isolation units were filling up and the highly contagious Delta variant first detected in India was now the dominant variant of Covid-19, causing up to 96.7 per cent of cases in Kenya. This percentage is higher compared to that of India, where several estimates show Delta accounts for 52 per cent of all cases.

Today, Delta has completely replaced Beta potentially in all of Africa, Prof Tulio de Oliveira, a specialist in the relatively new field of bioinformatics, or the application of information technology to medical research, recently wrote.

“The country received a lot of donor support and the expectation was that the government would have done a lot. We expected that resources would be allocated towards preparation for this wave. Yet, we are still at the same point,” argues Dr Were Onyino, president of the Kenya Medical Association (KMA).

The idea is to enforce measures before there is damage, opines Dr Kalebi.

“The fourth wave would have been handled better. The first four cases of Delta reported in Kisumu were our warning shots. Instead, the government downplayed the threat and political gatherings continued and the result is Kenya having Delta the dominant variant accounting for 96.7 per cent of all sequenced coronavirus cases,” Dr Kalebi added.

Given that the Delta variant is much more transmissible (research shows its two- to three-times as contagious as the original version of Sars-CoV-2 (2 to 3)) than its predecessors, like the Alpha variant, it does not appear to cause more severe disease. Even so, new data from the US indicates that unvaccinated people are 11 times more likely to die from Covid-19 than those who are fully vaccinated, bolstering evidence that the inoculations continue to provide powerful protection, even against the Delta variant.

The latest studies from the Centers for Disease Control and Prevention (CDC) also found that vaccinated people were nearly five times less likely to get infected and 10 times less likely to get so sick that they ended up in hospital.

The CDC "looked at Covid-19 cases, hospitalisations and deaths in 13 states and offers further evidence of the power of vaccination," Dr Rochelle Walensky, director of the CDC, said at a White House Covid-19 briefing on September 10.

In other parts of the world, the variant has spread fast, including in those who are partially vaccinated, overwhelming health services. With the continued uptick in Covid-19 cases.

But it is not all lost. As Dr Abdi Mohamed, chairperson of the Kenya Association of Private Hospitals said, many hospitals have been able to increase their capacity from equipment to human resources to better manage the disease, which remains a global pandemic.

“Having experienced the first, second, and third waves, private hospitals increased their capacity to handle Covid patients in readiness for the fourth wave. But these hospitals are only able to do so much due to global demand for equipment and medication. They have also waived many patients’ bills because insurance is not undertaking payment for Covid-19 such that it’s no longer sustainable,” noted Dr Mohamed.

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