No doubt the emergence of COVID-19 is a global problem that will have a global effect. African countries may, however, end up being disproportionately affected by the deadly virus given that most of these countries entered the pandemic while still battling poor health infrastructures, poverty, corruption, and other challenges. Moreover, the unfair global trade system has perpetually put poor African countries in a cycle of dependence that makes them too weak to combat a pandemic without donor assistance. Unfortunately, many donor countries are also badly hit by COVID-19. Arguably, in the face of uncertain foreign assistance, Africa will need to stand up to the challenge containing the spread of the coronavirus. This is a time to look inward to devise local strategies based on Africa’s everyday reality rather than blindly copying others.
Nigeria is Africa’s most populous country and it has recorded 493 confirmed cases and 17 deaths within 7 weeks the country confirmed its first case. The number of infection appears small, but considering the fact that testing in Nigeria has been few and selective, it is possible that the low figure is unreal, putting Nigeria at a high risk of a major outbreak of the disease. I analyze Nigeria’s vulnerability from an Afrocentric perspective but make propositions that are based on scientific findings. I argue that the medical use of Povidone-Iodine by every high-risk citizen can salvage the country from experiencing an outbreak of the coronavirus.
Rising To the Challenge
To contain the spread of the coronavirus, Nigeria followed the conventional approach by prohibiting large gatherings, banning flights, and the lockdown of major cities. But there are challenges. Nigeria is an oil-dependent economy and the sharp fall in international oil prices, following the pandemic leaves the government with little resources to fight COVID-19. Even though Nigeria should be testing around 5000 to 10000 per day, the country has only expanded its testing capacity to 1,500 per day and this capacity has not been fully utilized. As of March 2020, Nigeria has less than 100 ventilator units and about 350 intensive care units (ICU), 95% of which are currently in use by patients suffering from other health conditions. In other words, Nigeria has less than one ICU bed per one million people. In light of the current situation, Nigeria may not be able to avoid a large number of deaths if the country is hit hard by COVID-19.
The implication and impacts of the lockdown also raise some concerns. In Nigerian cities, the larger percentage of the population live packed together in slums with limited access to clean water and sanitation. In such crowded neighborhoods, ‘stay at home’ mainly creates a form of social gathering where social distancing is impracticable and where diseases can easily spread. The lockdown also means untold hardship to many Nigerians who survive mainly on daily income earned through street businesses. It is not surprising that many people disobeyed the stay- at- home in order to find work or water. Doubtless, for the poor, the fear of hunger is far more than the fear of the coronavirus. Another counterproductive outcome of lockdown is the surge in crime. Enforcing the lockdown has been challenging, sometimes leading to violence, as well as harming and killings of citizens by operatives. It is worth mentioning that the government invested in some food stimulus package for vulnerable families, but this is grossly inadequate and the distribution chaotic. Nigerian experience shows that African countries with crowded slums and large informal sector cannot follow the playbook of total lockdowns like countries in Europe and Asia. Most importantly, it shows African countries must quickly device containing measures appropriate for crowded environments and with minimal impact on the livelihood of the poor.
Looking Inward
No doubt, Nigeria would require extensive financial and technical support from the global community to contain the spread of COVID-19. But since these donor countries are the same ones who have been hard hit by the pandemic, the Nigerian healthcare sector must rise up to this challenge. However, this sector is poorly developed due to several factors. With just 4% of Nigerian budget allocated to healthcare, Nigeria spends less on health than nearly every country in the world and the country also has one of the poorest health outcome indicators. Nearly 20% of all global maternal deaths happen in Nigeria in 2015 while over 300,000 malaria deaths are recorded annually. The negative impact of western imperialism and globalization on Nigeria’s health sector cannot be underestimated. In 1986, the World Bank recommended that the local production of drugs in developing countries like Nigeria is not realistic which made Nigeria deemphasize local pharmaceutical production. Of course, such selfish recommendations discourage health innovations and make Africa’s healthcare sector perpetually import-dependent.
Nigeria particularly had since become a dumping ground for imported medicines which poses a serious threat to Nigeria’s health security during this pandemic. Access to imported medicines has now been difficult due to current travel bans around the world, while some critical medical supplies are now very scarce due to surge in demand. Unfortunately, any shortage of medical supplies may increase the influx of fake drugs in Nigeria. Currently, falsified chloroquine phosphate 250mg tablets manufactured in China have been found on circulation in Nigeria after it was announced that Chloroquine can be used for the treatment of COVID-19.
The opportunity
Despite the challenges, the COVID-19 pandemic provides an opportunity for reflection, creativity and innovation in healthcare, especially the pharmaceutical industry. Arguably, Nigeria urgently needs low-cost interventions that promise citizens the prevention of contracting COVID-19 even after the lockdown has been removed. It is for this reason I propose the medical use of Povidone-Iodine (PVP-I) solutions for the prevention and treatment of COVID-19 in Nigeria. There are hundreds of old and recent scientific studies confirming the efficacy of PVP-I against infectious diseases and viruses. Such findings are particularly useful for a poor country like Nigeria, which has a limited budget for research and development.
Povidone-Iodine (PVP-I) Against Coronavirus
Povidone-iodine (PVP-I) is an antiseptic used for treatment and prevention of infection in cuts, burns, and wounds as well as in surgical operating theatres. PVP-I formulations are usually at concentrations of 7.5–10.0% in solution, oral gargle, nasal and throat sprays, surgical scrub, ointment, and swabs. The efficacy of PVP-I as an antiviral agent is particularly important for the prevention of COVID-19 for clear reasons. Coronavirus disease is a respiratory virus that spreads when mucus or droplets containing the virus get into the body through eyes, nose, or throat. This spread often occurs through the hand and that is why handwashing with soap and the use of alcohol-based sanitizers are recommended. However, scientific evidence (Eggers et al 2015) shows that PVP-I hand wash and hand rub products are more effective in terms of viral reduction than alcoholic and non-alcoholic sanitizers, as well as antimicrobial soaps.
High frequency of mouth and nose touching has implications for transmission of infection. A study on face-touching behavior shows that on average, each observed student touched their face (including their mouth, nose, and eyes) 23 times per hour. Moreover, evidence shows that COVID-19 also called SARS-CoV-2 can be inhaled through the nose into the throat. Unfortunately, after coronavirus has gotten into the eyes, the nose or mouth of any individual, hand washing, or the use of sanitizer may be unhelpful. Medical experts suggest that recognizing the cells hosting viral entry and permitting viral replication is important to improve diagnoses and treatment of the novel coronavirus. Several studies (such as To et al, 2020 and Xu et al, 2020) aim at understanding viral load, (that is, the number of virus particles being carried by an infected person) found a high viral load in saliva at the early stage of COVID-19. Recently, Lescure et al (2020 preprint) also confirm that at an early stage of SARS-COV-2 infection, high viral loads were found in the upper respiratory tract samples. Sungnak et al (2020) report that higher viral loads can be observed in nasal swabs compared to those obtained from the throat.
These reports indicate that there is a high risk of transmission of the novel coronavirus during the very first days of symptoms. Anfinrud et al (2020, preprint) suggest that tiny droplets of saliva released while speaking can spread COVID-19. Sungnak et al (2020, preprint) particularly suggest that the nasal epithelium is an important portal for initial infection, and may serve as a key reservoir for viral spread across the respiratory mucosa and an important locus mediating viral transmission. Arguably, the early application of a potent antiviral agent to the mouth, nose and upper respiratory tract may be able to prevent the transmission of the disease. PVP–I solutions especially oral gargle, nasal and throat sprays may be useful for this purpose. Given the proven in vitro efficacy of PVP-I, early use of PVP-I based nasal spray and gargle mouth wash may significantly reduce viral load at the nose, mouth, and in the upper respiratory tract of an infected person thereby reducing the risk of transmission. This proposition is supported by Eggers et al (2015) which tested the in vitro efficacy of 4% PVP-I; skin cleanser, 7.5% PVP-I surgical scrub, and 1% PVP-I gargle/mouthwash against coronavirus (MERS-CoV) and Modified Vaccinia Virus Ankara (MVA). Their results show that each PVP-I-based product substantially reduced by ≥99.99% virus particles in contaminated skin, in the oral cavity and the oropharynx within 15 seconds of application.
Experts also opined that with respiratory viruses like coronaviruses, the outcome of infection can sometimes be determined by how much virus actually got into the body and started the infection off, so that getting infected with fewer virus particles will likely cause less severe illness. Higher initial viral load are however associated with death (Chu et al, 2004). Given the efficacy of PVP-I to reduce viral load, the use of PVP-I products may likely reduce the severity of disease thereby reducing mortality. Early detection of Covid-19 infection and treatment with an antiviral agent may also hold some benefits because despite high viral loads found in the mouth and upper respiratory tract at the onset of disease, in many cases, at that time, the virus has not marched down to attack the lungs and other vital organs. For example, Xu et al (2020) report a high expression level of SARS-CoV RNA in saliva specimens of observed patients, some of whom had not yet lung lesion, suggesting the value of early diagnosis of saliva, similarly to SARS-CoV-2 or COVID-19. They also reported an animal study on early events of SARS-CoV infection which showed that SARS-CoV was detected in oral swabs before blood test turned positive on the second day after viral challenge through the nasal cavity.
Recommendation for poor countries
Foremost, this study offers many opportunities for further studies on the applicability of PVP-I against COVID-19. Recently Kirk-Bayley et al (2020, draft) have recommended for the United Kingdom, the immediate and nation-wide use of PVP-I in healthcare workers and their patients because of the observed high risk of transmission of COVID-19 in UK hospitals. Nigeria is currently at a high risk of experiencing an explosion of COVID-19 beyond the capacity of its weak healthcare system. To avoid this looming disaster and in the absence of a vaccine, I believe the regular use of PVP-I nasal spray, mouth wash, and skin cleanser should be encouraged among the populace in addition to social distance practice. This will surely reduce cross infection and severity of COVID-19 cases. Moreover, PVP-I has an excellent safety and tolerability profile and it is also available over the counter. Unlike other antiseptics, significant resistance or cross-resistance has not been observed for PVP-I.
However, Nigeria’s health authorities should quickly facilitate necessary research and clinical trials to aid the implementation of PVP-I as a measure to contain the spread COVID-19 in Nigeria. There are very few commercially available iodine-based nasal sprays and gargle/ mouth wash in the country. The facilitation of their local production and wide distribution should be a major direction of health policy. Local production of the products will also create large scale employment thereby resuscitating a seemingly comatose pharmaceutical sector.
Note: The opinions expressed in this article are of the authors and not of her current employer.
Dr. Oyindamola Adejumo-Ayibiowu has 18 years’ experience in development research and economic management. She is a graduate of Economics, Obafemi Awolowo University (OAU), ile-ife, Master’s degree in Poverty Reduction and Development Management (International), University of Birmingham, UK, and Ph.D. Development studies, University of South Africa, Pretoria. Her professional experiences include the Central Bank of Nigeria, UNDP, EU, World Bank, AGRA, and IFAD. She currently works with the Federal Inland Revenue Service.