Six weeks ago I wrote to Matangi Tonga raising concerns about the timing of the reopening of schools following the National Lockdown. I raised those concerns because I was not convinced that Tonga could be truly satisfied that there was no COVID-19 virus circulating in the community.
The passage of time seems to suggest that the virus has, indeed, not arrived. There have been no reported cases of COVID-19 (although no one has been tested) and the public has responded to the lockdown and other restrictions with, generally, overwhelming support.
Time has given Tonga a great opportunity to prepare itself for the virus and any cases that it might produce. The question is, has this time been used wisely and with urgency to prepare Tonga for the future risks?
Those risks, however small, exist even now.
Radio New Zealand recently reported an Ecuadorian fishing vessel arriving in French Polynesia with 29 of 30 crew diagnosed with COVID-19. Although this ship appears to have left Ecuador in April and so the cases likely originated from there, the incident does raise concerns about whether the virus may be circulating among the crews of foreign fishing vessels and therefore whether, through on-ocean contact, it might be brought into Tonga.
Then there is the ever-present risk that a breakdown in infection control procedures at Fuaʻamotu airport or Nukuʻalofa port could allow the virus in.
And even today, the Queensland Government has reported a second case where they believe the virus may have lain “dormant” in a person for up to 10 weeks before causing illness.
The current ban on international travellers entering Tonga is due to be lifted on the 12th of June.
There is pressure from Tongans stranded overseas to be allowed to return, and the government has established a group to advise on the arrangements for reopening the borders.
And it is true that Tonga cannot stay cut off from the rest of the world forever, but it must do all it can to prevent the virus from getting in and must be properly prepared to respond to a COVID-19 outbreak should it occur.
Preventing the entry of the virus when the borders reopen must involve mandatory COVID-19 testing (RT-PCR) and medical clearance before travel. Quarantine for 14 days after arrival must occur, and travellers must be tested again prior to release. A period of pre-travel quarantine should also be considered. These requirements may seem to be tough, but the consequences of an outbreak in Tonga could, as I have previously said, be terrible.
Scenario modelling suggests that an uncontrolled outbreak might, over a six-month period, cause up to 400 Tongan deaths. Hospital requirements would peak at 230 acute beds and 200 critical care beds. Mild cases (up to 1,500 at the height of the outbreak) would need to be treated at home, increasing the risk of spread.
The toll on the community would be huge; the toll on the health system crushing.
Even under the best case scenario, using a rolling series of strong lockdowns, the numbers of deaths could still be upwards of 50, and the peak hospital bed requirements eight acute and nine critical care. If the ability to suppress the outbreak is even slightly less than modelled, the numbers of deaths and hospitalisations increases considerably.
How should Tonga prepare?
There is still no in-country testing capability. Three test units have arrived, but the laboratory — at least from external inspection — appears not to have been completed. The Minister for Health is reported as advising Parliament that the necessary control samples for the test units have not yet arrived. It is also not clear how many test kits are available or how much personal protective equipment (PPE) has arrived.
When testing is available it must be done widely. There are plenty of studies — China, France and the USA — that have shown that the virus circulates in the community well before the first case is identified, and limiting testing to those who meet a narrow case definition will almost certainly mean that cases are missed.
But importantly, COVID-19 testing must start now, not wait until the borders reopen.
Testing must include everyone with a cold or flu, or any other respiratory illness. The government will need to have on hand at least 20,000 test kits to cover the first couple of months.
An extensive contact tracing system must be set up now.
It has been suggested in the literature that there should be at least one contact tracer per 1,000 population. This means around 110 across the country and 75 in Tongatapu.
Contact tracers do not need to be health workers. They should be based in their communities, properly equipped (including with PPE, and with systems to record and rapidly report their findings), and can be trained using on-line courses.
Quarantine arrangements for arriving passengers and contacts of cases must be put in place and be ready to go. Hotels and possibly school and university accommodation blocks should be used, which has the benefit of providing work and income for those business and their employees. If the numbers of people requiring quarantine exceed capacity, arrangements for home quarantine will need to be set up and should be planned for now. If home quarantine is required, the risk of an outbreak growing will be much higher.
Facilities for treatment
Facilities for treatment must be set up, commissioned and made operational.
Tonga’s COVID-19 treatment hospital should have as a minimum a 10-bed acute facility, with isolation capability, alongside a five-bed intensive care unit (ICU) with mechanical ventilation capability, fully equipped and ready to go.
There need to be contingency plans to rapidly increase these bed numbers to at least 40 acute beds and 30 ICU beds. This will need external support, but the plans must be ready to go as soon as there is any sign that case numbers will exceed what is in place.
The government has said that it plans to use the Muʻa Health Centre to treat all COVID-19 patients. This concept should be reconsidered.
Muʻa is too small for anything other than a tiny outbreak. It is a long way from the main laboratory and radiology services. It will split the specialist workforce. If the numbers of cases exceed its capacity, moving the service to a bigger facility will be risky and difficult.
COVID-19 treatment should be done at Vaiola Hospital, utilising a mix of existing facilities and, if necessary, expanding using modular units or tents. Muʻa could be used for other purposes suitable for a standalone unit.
In many countries, COVID-19 has taken a heavy toll on health workers, with loss of staff through both illness and death. Tonga cannot afford to lose any of its health workers to COVID-19. Adequate quantities of PPE must be obtained — a minimum of three months’ supply sufficient to manage the anticipated caseload, including mild cases treated in the home.
Masks should be obtained, not only for health workers, but for cases, contacts, and maybe even the general public.
Community support for the measures that may need to be implemented — public event bans, school closures, lockdowns etc — is critical to their success. They have worked well since the end of March. But people need to know why these measures are being used and understand what might happen if they do not work. They also deserve to know exactly what the government has put in place to manage an outbreak, keep people safe and treat them properly. New Zealand is an exemplar in communicating with the community and engaging their support, and Tonga could do well to adopt some of their approaches, particularly their alert system.
All of these things need to be in place before Tonga reopens its borders.
Tongans who live in Tonga deserve the same standard of care as those who live overseas. It is not enough to accept that isolation is a reason for anything less.
This pandemic, for all its woes and hardships, is also an opportunity. Aid money is coming in. Using that to build up the capacity of the health system now means that this can be kept for the future. Wouldn’t it be great if Vaiola were to have a state-of-the-art five-bed ICU that can treat anyone who needs that level of care even after COVID-19 abates? The staff can do it, if only the facility is there. And it could be.
And so we await the arrival of the virus. I hope Tonga is well prepared when it does.
Dr Russ Schedlich MB BS, MPH, FRACMA
Tofoa, Tongatapu, Kingdom of Tonga.