On January 12, 2021, one of the authors of this piece was called to see a pregnant woman who was scheduled for an elective caesarean section.

On admission, she was well and had no symptoms of SARS-CoV-2 (COVID-19). On day of surgery, she complained of nasal congestion and loss of smell but not taste. A rapid diagnostic test (RDT) was done in the theatre, which came back negative for COVID-19.

The existing protocol at the facility for conducting caesarean sections during the pandemic is to do a COVID-19 symptom and temperature check for all pregnant women. A COVID-19 test is only conducted for those with symptoms suggestive of COVID-19. All negative cases are then managed using normal surgical protocol for personal protective equipment (PPE)—surgical face masks, face shields and reusable theatre operative gowns, while positive cases are operated using complete coverall as prescribed by the COVID-19 PPE protocol.

Surgery was thus carried out through the normal procedure, resulting in the birth of a healthy baby. The mother was subsequently transferred through the recovery ward to the maternity ward, where other patients were admitted. The theater was also used for other cases that day without fumigation.

On post-operative day one, she complained of severe back pain with worsened nasal congestion. After retaking a COVID-19 diagnostic test, she was confirmed positive. The mother and baby were subsequently moved to the isolation ward where they were nursed together. She was stable throughout her stay at the isolation ward. Her baby had a mild fever of 37.5 degrees Celsius, but a test for COVID-19 came back negative. The fever subsided the following day without any treatment.

Mother was managed based on the facility protocol for COVID-19 and was encouraged to practice exclusive breastfeeding while wearing face mask and observing hand hygiene. She was discharged on post-operation day 5 in a stable condition to self-isolate at home while the rest of her follow-up care was done through phone and special appointments due to her COVID-19 status. She had a physical review two weeks post-discharge and both mother and baby were stable and well.

The initial negative COVID-19 RDT result gave the surgical team and the other health care workers who attended to the patient a sense of safety. However, her subsequent positive result caused anxiety and stress, particularly among the staff who handled the patient prior to knowing of her COVID-19 positive result.

Staff who were exposed were screened for COVID-19, with some testing positive and having to be put on treatment and to self-isolate. Three immediate contacts tested positive: one patient, one doctor, and one anesthetist. In subsequent weeks, seven other contacts of her initial contacts tested positive. By the end of week four, 34 staff had tested positive. Most contacts could be traced to this case, as the health care workers worked in close proximity with each other and shared common spaces. A common reason for the high-risk infection posed to health care workers from undiagnosed patients is inadequate full cover PPEs, which necessitates that they are reserved for confirmed patients.

This story is not unique and exposes the stress that health care workers (HCWs) go through in providing services during this pandemic. For many HCWs in the global South, COVID-19 pandemic has exacerbated existing challenges in our already overstrained and underfunded healthcare systems that are inadequately prepared to respond to the pandemic. The result is the increased or high risks of infection among health care workers—a major cause of stress.

We present this case study to illustrate the challenges and needs of HCWs in sub-Saharan Africa, drawing lessons from a study we launched in Ghana in April 2020 at the beginning of the COVID-19 pandemic to assess preparedness to respond to COVID-19 and its impact on healthcare workers.

We found that, as of April/May 2020, when Ghana had recorded less than 10,000 cases, about 7 out of 10 healthcare workers were experiencing moderate or severe stress (68%) and burnout (67%). Lack of preparedness of HCWs was one of the factors contributing to the high stress and burnout, with less than a third (28%) feeling prepared at the time. Fear of infection partially accounted for the relationship between perceived preparedness and stress/burnout. In a second phase of the survey conducted between Sept 2020 and Feb 2021, moderate to severe stress and burnout remained high at nearly 70%.

A potential reason for the continual high stress and burnout among HCW is the increasing number of confirmed cases in the country. This situation is further confirmed by this case study where many of the staff got infected from a single case, leading to increased stress among staff. At the time of writing this paper (March 2021), COVID-19 is resurging in Ghana, with 500+ confirmed cases reported daily. Current number of confirmed cases is well over 84,000, with 600+ deaths. Yet, risk perception is low among the general population while national and local mitigation efforts are insufficient to slow the pandemic. This current reality, thus, has a potential to further overwhelm the medical system, and in particular exacerbate the stress and burnout HCWs are experiencing under the pandemic.

This case study reveals an interesting pathway through which the mother’s COVD-19 status was found. Clearly, the low routine surveillance for COVID-19 implies that patients may not be identified positive for the virus until after they have been cared for by providers as illustrated by this case study. Current data in Ghana shows that almost 60% of COVID-19 cases are reported through active surveillance (including contact tracing), rather than routine surveillance. Additionally, although the Ghana society of obstetricians and gynaecologists recommend that ALL elective surgical cases should have mandatory COVID-19 testing before admission, this is often not done. One other important concern is the low sensitivity of the RDT resulting in false-negative results as happened in this case study. These situations put HCWs at risk, as they are not certain about the COVID-19 status of patients they are caring for. This, therefore, creates fear of infection among providers, a situation we found in our study to be associated with increased stress and burnout.

It is established that high stress and burnout lead to decreased job satisfaction and commitment, lower productivity and effectiveness, and poor quality of care, with risks to staff and patient safety. Stress and burnout are also associated with depression, cardiovascular disease and premature mortality. HCW burnout is expensive for the health system given its associations with quality of care, absenteeism, and workforce turnover. It is therefore important to address the high stress and burnout among HCWs and service providers.

Our surveys present concrete and low-cost ways to lower HCWs stress. Providers who had undergone training on how to diagnose, isolate, and treat COVID-19 patients felt more prepared hence, were much less likely to experience burnout. Ensuring that HCWs feel the appreciation of management for efforts during this challenging time can significantly improve their job satisfaction resulting in better patient outcomes. To address concerns of staff including stress and burnout as a result of their high-risk exposure, as observed in this case study, communication from management is important. Burnout can be prevented by focusing on strict adherence to COVID-19 protocols, staff training, clear and consistent communication, introducing provider incentives and offering stress reduction strategies to HCWs.

Similar to this case study, HCWs we surveyed stressed the need for more PPEs and availability of isolation wards. This concern is similar to the same dearth of resources that have plagued even the wealthiest countries. Our research suggests the need to improve the morale, and for that matter the quality of care of patients, through simple, low-cost training and workforce incentives in Ghana’s hospitals and clinics.

Finally, the resurgence of COVID-19, combined with the realities of a strained and overburdened health care system and workforce, requires the country to take a more stringent course of action in its national response [risk communication, enforcement of mask wearing, no large gatherings, mass vaccinations, etc.]. These can lower transmission risk and reduce the burden caused by increasing cases among HCWs. Implementing these recommendations can help strengthen national capacity, mitigate the pandemic, and better prepare and support HCWs.

This case study illustrates the potential dangers, challenges and high risk of COVID-19 infection among HCWs especially when this is associated with inadequate and untimely testing of patients prior to clinical and surgical procedures. The lack of adequate and appropriate PPEs at health facilities poses one of the greatest risks to staff. COVID-19 protocols must be strictly observed to avoid unnecessary staff stress and burnout due to fear of infection.

This case study and summary was written by Dr. Hawa Malechi., Dr. Patience Afulani, Dr. Akua Gyamerah, Dr. Raymond Aborigo, Dr. Jerry John Nutor and Dr. Koku Awoonor-Williams.

Study website: https://covid-19africapreparedness.ucsf.edu/phase-1-study-results