MUII-plus Participation in COVID-19 response

Dr. Pritch Kabata and Dr. Saudah Namubiru Kizito are some of the MUII-plus fellows that are involved in the COVID-19 response in Uganda and they shared with us their first hand experiences at the front-line.

Pritch is a newly qualified internal medicine physician with particular interest in critical care medicine and clinical immunology. He is currently volunteering at the main national regional referral hospital in Uganda – Mulago Hospital COVID – 19 Intensive Care Unit (ICU) which treats the severe cases of COVID – 19. Pritch started working at the ICU in July 2020 when the first patient was taken to ICU. Before that, he was working in the general COVID-19 unit from June 2008 as a Senior Health Officer.

On the other hand, Saudah is a medical doctor with post graduate training in Medical Microbiology (Masters of Medicine in Microbiology) and is yet to graduate. She is particularly interested in general disease prevention through instituting appropriate infection prevention and control measures.

Just like the picture world over, Uganda is experiencing a rapidly changing COVID-19 situation. As a country, we have progressed to phase 4 of the COVID-19 pandemic where we are witnessing cases and deaths in clusters in the communities in different parts of the country. As of 17^th December, the country had registered 30,071 confirmed cases and 230 deaths, according to Ministry of Health – Uganda.  It is important to note however that because testing is not widely available and accessible to the common man, with the average cost for a test going for $65 many cases are definitely going unreported.

Uganda is currently seeing a surge in the numbers of COVID – 19 cases and subsequently, the proportion that presents with critical illnesses has increased. Unfortunately, with the current shortage of resources, a situation exacerbated by an already overly stretched health care sector, not everyone who urgently needs intensive care can access an intensive care Unit (UCI). A research titled “Assessment of the current capacity of Intensive Care Units (ICU) in Uganda; a descriptive study,” by Patience Atumanya, et al shows that the country has 55 functional intensive care beds in the 12 ICUs that are operational. The report indicates that of the 14 ICUs in the country, 12 are operational and two are non-functional due to lack of human resource.

Due to limited resources, ICU can only take a small number of patients requiring advanced care. “My hardest time of the shift is attending to the consults from the High Dependence Unit (HDU) for ICU admissions. We literally ‘cherry-pick’ those patients who are mostly likely to benefit from ICU care. These decisions are guided by the MOH guidelines for COVID19 ICU admissions. Personally I find it difficult but we follow the guidelines,” noted Dr. Kabata.

Dr. Kabata goes on to testify that his involvement in the ICU has changed his understanding and perspective of COVID-19. For starters while only 5 to 15 percent of patients (or even less) may require ICU care, the population is diverse with both young and old people involved. However, a common denominator from his observation, is that overweight and obese patients appear to get the severe end of the disease spectrum (this has been validated in other studies). His perspective of a “good death” has also changed. While it’s imperative as health care workers to do all they can to save lives, he noted that he is learning that prolonging suffering of patients may not be in their best interests and its high time for the population as a whole to get into the practice of getting advanced directives as pertains end of life care.

His two most memorable patient interactions were the following. The first was a 30-year-old obese patient who was in HDU and he needed advanced care, although there were no available beds at that time. When Dr. Kabata went to review him he was saturating at around 60% (normal is between 92 and 96%) despite being on oxygen therapy with a non-rebreather mask and nasal prongs and quite distressed. On simple manoeuvres such as adjusting the mask to prevent leaks his saturation reached around 69%. Around that time of observing him, lunch was served and he said he was hungry and needed to eat. By eating it meant that he would remove his mask and that would cause further deterioration. After trying to explain to him the pros and cons of removing the mask the patient insisted that he was hungry. It was a philosophical moment witnessing two basic human needs conflicting with each other.

The other one was a 69-year-old female who had been unwell for two weeks by the time of admission. When she was put on respiratory support (non-invasive) she was very appreciative and said “Doctor I cannot wait to come out of here and tell others COVID19 is real.” Unfortunately, she did not make out of the ICU.

Young adults may think their age group isn’t at risk from COVID-19, but the cases reported lately suggest that the idea is dangerously mistaken. “In the ICU we see both young and old patients losing their lives as they fight COVID-19 with all available life supporting resources. The more reason the young people should not think that they are more protected than the elderly ones,” noted Dr. Kabata. People need to take very good care of themselves by following the Ministry of Health SOPs on COVID-19 prevention regardless of their age. 

There has been a noted lapse in adherence to the COVID-19 SOPs, compared to the earlier days of the pandemic. That the country is undergoing an electioneering period, has only served to make the situation worse, with a tendency to politicize everything in the country, including response to warnings from government on COVID-19 infection prevention and control.

The attitudes of the general population require continuous engagement on basic aspects on infection prevention and control, and this is one of the areas where Dr. Sauda is focusing her skills, experience and passion working with communities.  She has undertaken COVID-19 infection prevention and control (IPC) activities like community engagements of market vendors on COVID-19 basic facts and its infection prevention and control, and training of Village Health Team (VHT) workers on their role in prevention of COVID 19 and in the surveillance and actual case management of COVID 19 patients. Her interest on the clinical immunology front is to develop hypotheses on why some people get severe disease while others do not. Other researchers interested in this area are encouraged to come join in as the world together joins hands in the prevention against COVID-19. Identifying immunological factors that are associated with severe disease presentation could also pave way for more immune modulating therapies. Some of the challenges in this line of research have been stigma in sample processing of patients with COVID-19. Even though COVID-19 is not a blood borne infection some laboratories are not keen to work on such samples. Furthermore, there was a lot of stigma especially in the beginning against clinicians managing COVID-19 cases and families whose members tested or succumbed to COVID-19. This is however easing out as the disease continues to spread.

“In general, it’s been a bitter sweet experience volunteering in the COVID-19 ICU unit. We have also had success stories and some have even written their stories in the newspapers.” Dr. Kabata said.