The World Health Organisation (WHO) has put in place a strict set of measures countries should adopt to avoid the spread of Covid-19, but some of these have been criticised for being too economically damaging to adopt – and potentially not as effective – in a developing country context.

Rosa Marlene Cuco, national director of public health at the Ministry of Health, said the ministry is well aware of the challenges the Mozambique government is facing, especially of the difficulties of imposing the WHO’s recommendation of a 14-day quarantines for anyone who may have contracted the virus, in circumstances where families all share one room.

“What we’ve been saying is that the person in quarantine should stay in one room and avoid sharing objects with the others until the 14 days have passed. So far we have not had any case that has made this impossible but it is a question that is part of our response plan to the coronavirus that we are seeking funding for,” she told Zitamar.

The government, which is seeking $700m in funds from international partners to help with its response to Covid-19, wants to establish isolation tents in all provinces for people who are homeless, or have no alternative options for quarantining.

The WHO also advises that governments ‘test test test’. Mozambique has done 98 tests, seven of which were positive, according to the latest government statistics.

“We have to recognise our capabilities. For now we have about 2,000 tests so we prioritise suspected cases, those with symptoms,” Cuco said. “If you see our data you will find that even in suspected cases, most of them were negative. We are following the WHO recommendations to the letter.”

The WHO also recommends washing hands with soap and water frequently to reduce the risk of infection. However, only 45% of the Mozambican population have access to clean water.

There are short-term steps the government could take immediately. “In response to the 2018 cholera outbreak, for example, the Zambian government mandated that utilities and private water providers supply water for free in specific areas where access was an issue. In response to coronavirus, Rwanda is putting in place mobile hand washing stations in markets and bus stations, and other public spaces,” said Adam Garley, Mozambique country director of WaterAid. 

However, soap is frequently stolen from public hand washing facilities. During the ebola crisis in West Africa, agencies addressed this by using chlorinated water, instead.

“However, the consensus is that chlorinated water won’t be effective against Covid-19; we need to use soap or hand sanitiser. If that’s the case then hand washing stations will need to be staffed to ensure the soap doesn’t go missing,” said Garley. “In instances where people don’t have access to soap, they could use fresh ash – which is the next best thing in the absence of soap. But if people start doing aid distributions soap is the obvious thing to try to get to as many places as possible.”

It’s essential that WHO’s advice on hygiene reaches all members of the population – a major challenge in a vast and multilingual country like Mozambique, with high illiteracy rates.

“Regular hand-washing, covering nose and mouth when coughing or sneezing, avoiding close contact with people who are ill, these are all important messages – and the government needs to be clear and consistent in getting it out to everyone,” said Garley. “All mediums need to be deployed – TV, radio, social media, chapas could play recorded messages. And the message shouldn’t change; it’s important that all people should hear the same thing, but we need to recognise limitations people will face based on their context and provide them with the support they need to follow the guidance. Addressing the lack of water for handwashing will require a huge coordinated effort and mobilisation of resources.”

Cuco told Zitamar the issue of handwashing has been discussed, and “will be addressed in the scientific group created to guide the government.” 

How will the virus spread

There is still uncertainty how quickly the virus will spread in Mozambique and if the current government measures put in place are enough to slow it.

There are rumours that the novel coronavirus, like other flu viruses, may not travel as well in hot, humid environments, as it does in cold, dry climates – however, there is no clear evidence for this.

“Practicing preventive measures is the best way to avoid getting the virus. That is why we continue to emphasize frequent handwashing, and anyone who thinks they are sick should wear a mask.  In the absence of a mask, they should cover their nose and mouth with a bandana or similar item,” Sarah Bennett, Commander, United States Public Health Service, and Head of the International Task Force for Covid-19, CDC, told a press conference on Thursday.  

Bennet said CDC has been advising governments on how to adapt measures to their own country and social context, and has published guidance to health practitioners on its website.

“We are currently at low risk. We have confirmed the existence of positive cases, but on a small scale,” said Cuco. “We are doing everything we can to ensure that we remain at low risk, and we are trying to contain cases by isolating those affected and their contacts.

Communities at risk

The majority of severe Covid-19 cases are among the elderly, particularly those over 70. The Mozambican population is young,  but since the virus is likely to be of particular concern for communities with high rates of tuberculosis and HIV, a significant number of people are at risk in Mozambique.

“From the Chinese experience, we have seen that people with chronic lung disease are more likely to have increased severity of Covid-19. On that basis, we are concerned that people with undiagnosed active TB, or people currently undergoing treatment for TB, may have increased risk of developing more severe Covid-19 disease if they become infected with SARS-COV-2,” Emily Wong, faculty member of the Africa Health Research Institute, University of KwaZulu-Natal wrote for The Conversation. Mozambique has one of the world’s lowest TB case detection rates, of 37%. People who have recovered from TB, but have weakened lungs, may also be at higher risk.

In general, as HIV infection has a major impact on lung health and immunity, experts are also concerned that HIV infection may also affect COVID-19 severity — although people on antiretroviral therapy should not be at significantly increased risk relative to similarly aged peers.

The UN estimated in 2018 that 56% of the estimated 2.2 million people living with HIV in Mozambique are not on treatment and therefore have suppressed immune systems.

South Africa is now preparing how to maintain sustained access to HIV and TB care, Wong said. The President’s Emergency Plan for AIDS Relief (PEPFAR) and the South African HIV Clinicians Society are urging the health system to make six months’ worth of antiretrovirals available to people to save them from having to visit their clinics every month.

The Ministry of Health did not return calls seeking comment from Zitamar on what preparations Mozambique is taking to ensure the continuation of HIV and TB care.

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