COVID-19 cases in Ghana are dramatically increasing, resulting in many preventable deaths and the resultant pressure on the already weak health care system.

The ongoing pandemic has disrupted normal daily activities with negative externalities on the various sectors of the global economy. SARS-COV-2, the virus that causes the Coronavirus disease, has been the greatest threat to human civilization since the 1918 flu pandemic. After WHO declared COVID-19 a public health emergency of international concern, many countries have taken multiple steps to contain the virus's spread. Globally, COVID-19 has infected more than 11 million people and has caused more than 500,000 deaths according to data available on the Johns Hopkins COVID-19 dashboard1. Meanwhile, The World Health Organization has warned countries to step up measures to contain the virus because the worst is yet to come, given the current trajectory.

Recent evidence indicates that SARS-COV-2 has undergone a series of mutations making it more infectious2. According to the CDC, COVID-19 is believed to be transmitted from person to person after coming into proximity (within 6 feet) with an infected person's respiratory droplets or contaminated surfaces. Much is still being discovered about the transmissibility of COVID-19 from asymptomatic persons. Currently, there is no cure for COVID-19, and no vaccine is readily available. Treatment is mainly supportive with some drugs proving effective in reducing hospital stay and mortality.

Ghana was ranked 105 out of 195 countries in the 2019 Global Health Security (GHS) Index rating. It scored way below the average score of 40.2/1003. International health experts developed the GHS index in a project led by the Nuclear Threat Initiative (NTI). The Johns Hopkins Center for Health Security and the Economist Intelligent Unit (EIU) in assessing a country's capability in rapidly responding to public health emergencies. Our ratings indicate that our health system is fundamentally weak. As such, we are not adequately prepared for epidemics or pandemics unless we address essential gaps in our health system.

Ghana has now recorded over 19,388 confirmed cases of coronavirus, with 117 deaths, bringing the mortality rate to 0.6%. Ghana has the highest confirmed cases per capita of COVID-19 among its neighbouring countries (see figure 1) as of July 3, 2020. The number of confirmed cases and deaths are steadily increasing.

The government of Ghana instituted a series of measures to contain the spread of COVID-19, which seemed effective at the early stages of the pandemic. Some of the measures instituted included the closure of borders to international travel, restriction on public gatherings, the partial lockdown of hotspots, closure of educational institutions, and religious congregation. A team of contact tracers was employed to help break the chain of transmission.

However, after 3 weeks into the lockdown, the economic trade-offs and ramifications on the national kitty called for a slight modification of the initial guidelines. Available evidence and the performance indicators at the time did not support the government's decision to relax the previously instituted guidelines. The worrying trend of the COVID-19 pandemic in Ghana has exposed the inefficiencies in current guidelines and calls for a review of existing protocols.

Alternatives

Maintain Status quo: Current guidelines and various ongoing activities in the country are negatively affecting the country's ability to contain the rampant community spread of COVID-19. The relaxation of the restrictions on public gathering, including the disregard for social distancing and mask-wearing in the ongoing national voter registration card centres, and many other social gatherings including marketplaces will lead to a massive surge in cases and hospitalizations in the coming weeks. Policies that maintain the status quo indicate that our measures are not working. Instead, millions of people, including health workers, are exposed to incalculable risk. So, what other evidence-based alternatives are available to contain the virus.

Re-impose restrictions and re-activate contact tracing task force as soon as possible: The consistent increase in the number of cases and deaths calls for a more stringent measure in addressing the ongoing COVID-19 pandemic in Ghana. For example, after prematurely lifting restrictions, some states in the United States of America and some countries such as Madagascar and Saudi Arabia saw a massive surge in cases resulting in the re-imposition of restrictions. The science and evidence are unequivocal. The only way to contain the virus is to prevent people from coming into contact with infected persons. I believe re-imposing restrictions will give the government and the health system the time to better re-strategize and handle the ongoing pandemic. Contact tracing is the most critical mechanism in breaking the chain of infection. Without active contact tracing, the rampant community spread will continue until a time when our health system will be overwhelmed by the increase in cases. I believe investing in contact tracers, contact tracer managers and supervisors will go a long way to ensuring that community spread is limited and contained. The importance of contact tracing cannot be overstated. Countries are spending a considerable amount of money on hiring contact tracers.

Enforcing Social distancing and mask-wearing at registration centres, marketplaces and other gatherings: The ongoing national voter registration exercise poses a significant risk to those taking part in the activity. The disregard for social distancing and mask-wearing at the various centres can cause a dramatic surge in the number of cases in the coming weeks. Ideally, the exercise should be put on hold until our performance indicators improve.

However, in the absence of ideal, the least we can do is ensure that social distancing and mask-wearing protocols are strictly observed, even if the security apparatus should be involved. Similarly, the COVID – 19 safety protocols should be strictly enforced in other social gatherings which have similar risk levels.

Increase testing volume and Provide Personal Protective Equipment (PPE): Testing is critical in identifying positive cases and ensuring they do not pose a threat to their family, friends, and the general public. Our testing capacity is woefully inadequate. I believe decentralizing testing centres equipped with rapid testing kits will significantly improve our ability to detect positive cases in real-time and institute isolation measures and trace contacts. The medical community has seen an escalation in the number of positive cases among its members. The loss of renowned doctors and other allied health workers makes it imperative for the government and other relevant stakeholders to provide the health fraternity with the requisite PPEs. The safety and morale of health workers are critical in these times.

Use Evidence-based indicators in lifting future restrictions: The easing of limitations and the re-opening of major economic activities should be based on scientific evidence. The scientific bases for lifting restrictions should include the number of new cases, the number of new deaths, the proportion of tests reporting as positive (% positivity), number of tests performed daily, and hospitalization rate. The improvement in these indicators should be the basis for lifting restrictions. I expect the official advisory team to come up with evidence-based guidelines in lifting future restrictions on the ongoing pandemic.

Analysis and recommendation: re-imposing restrictions and activating contact tracing as well as increasing testing volume and provision of adequate PPE seem to be the two most favourable amongst all the four alternatives. These alternatives have promising results in containing the spread of COVID-19. The benefits of containing the community spread may outweigh the cost of implementation. New Zealand and South Korea are some of the few countries that have succeeded in containing the spread of the ongoing pandemic. These countries took decisive action, which ensured a coordinated response. Successful countries invested in robust contact tracing mechanisms. They boosted their testing capacity to pick up new cases as early as possible. The current state of affairs is becoming very scary, and bold steps should be taken to address Ghana's COVID-19 situation.

Conclusion: Our fragile health care system is already overwhelmed by the increasing cases of COVID-19 infections. The window of opportunity is closing pretty fast. The leadership in our country must prioritize the health of the public by considering the alternative policies discussed before irreversible harm occurs.