Sanitize the Man,Sanitize the Car: COVID-19 Disease Control in Botswana

Abstract

COVID-19 has dominated global health since it became a global pandemic in early 2020. It has stressed global health systems and pushed many other health concerns to the back burner. There is an urgent need to look for innovative ways to tackle the pandemic in a sustainable and transferrable manner. This article examines the COVID-19 control measures in Botswana. It describes the innovative government actions taken to control the pandemic. It also presents the observations of the authors, who have observed these actions around the country. They report on the effectiveness of the control cordon belts and the disinfection of people and animals as well as the sanitizing of objects like shoes and cars that pass across the control boundaries. Based upon the effectiveness of the control measures in Botswana, the authors recommend an innovative disease control framework for COVID-19 and other infectious diseases which they contend is replicable in other countries.

Keywords

COVID-19 pandemic disease control sanitization Botswana

Introduction

The COVID-19 pandemic is a deadly respiratory infectious disease, which has ravaged the population of countries around the world since it was declared a pandemic by the World Health Organization (WHO) in March 2020. The causative agent is the novel SARS-COV-2 virus which is a coronavirus. The pandemic has been a global nightmare, presenting mammoth challenges to humankind (e.g., Daud, 2021; Saha & Vasuprada, 2021) and dire socio-economic impacts (Agwanda et al., 2021). It continues to pose a multi-facetted threat to human health, and countries struggle to put measures in place to control it (Agojo, 2021). Botswana has responded to this threat by adopting vigilant, proactive, and strict measures drawn from this African country’s previous experience contending with zoonotic diseases.

Botswana

Botswana is a large land locked country in Southern Africa (Figure 1), with a surface area of 581,730 km² and population of about 2.3 million people (Statistics Botswana, 2020). The country is mostly flat and has a low population density of 3 people per km². The COVID-19 incidence in the country, as of May 20, 2022 was over 300,000 (WHO, 2022), with almost 2,700 fatalities. In comparison, South Africa led the continent with almost 4 million cases and more than 100,000 deaths, followed by Morocco with about 1.2 million cases and above 16,000 deaths. Outside the continent, the USA had more than 82 million cases and about 1 million deaths, followed by India with just above 43 million cases and about 0.5 million fatalities.

Figure 1.

Source: Wikiwand at https://www.wikiwand.com/en/Geography_of_Botswana

The statistics in Botswana are very low in comparison to other countries in Africa and elsewhere. The country has made great strides in controlling the COVID-19 pandemic, using methods that include those that had been used in the past to control infectious diseases in livestock, such as the highly contagious foot and mouth disease (FMD) and the contagious bovine pleuropneumonia (CBPP), commonly known as the cattle lung disease (Letshwenyo et al., 2004; Marobela-Raborokgwe, 2011).

Botswana has been historically dependent on its cattle industry for national revenue and for the sustenance of rural livelihoods. As a result, zoonotic afflictions of cattle are relevant to debates about public health. This is so because whenever they erupt into epidemics, they have great potential to undermine food security and thus compromise human health. Toward the end of the twentieth century the world experienced a list of new viral diseases, including but by no means limited to Ebola in West Africa, SARS, and HIV/AIDS, most of which continue to pose a global public health threat to date (Morens et al., 2004). The ongoing COVID-19 crisis is in this respect the latest in a series of major viral outbreaks that have left a lasting legacy.

Botswana’s Share of Pandemics

Botswana, like many other nations, has historically been shaped by infectious diseases arising from natural causes as well as human agency. Notable examples include the rinderpest pandemic of 1896–1897, the great Spanish influenza of 1918–1919, the still ongoing challenge of HIV/AIDS pandemic, the ever-present and highly contagious FMD, as well as the CBPP epidemic of 1995–1997. FMD, a highly contagious viral disease that afflicts all cloven hoof animals, including cattle, is endemic to Botswana but often erupts into epidemics, depending on mutations and the interplay between contact and environmental transmissions.

Likewise, CBPP is a highly infectious respiratory disease with great potentiality to decimate large populations of cattle within a short period of time. It is a constant threat to the country’s cattle industry. Epidemics of these livestock diseases have historically destroyed livelihoods, compromised food security, and caused human infections thus negatively impacting public health (Thakadu & Reetsang, 2019). Cattle rearing is commonplace in Botswana, and cattle ownership is a symbol of status. This causes humans to be in close proximity to the animals, thus increasing the chance of being infected.

Between 1895 and 1899, Botswana was plagued by a combination of severe drought and locust infestations, which were compounded by the outbreak of rinderpest and a surge in human suffering (Marquardt, 2017; Molosiwa, 2014). This tripartite of pestilences resulted in up to 20% of the country’s population perishing, along with most of the territory’s livestock and much of its wildlife. Throughout the country both official and unofficial estimates consistently calculated livestock destruction as ranging upwards to 90%.

According to the Bechuanaland Annual Report for 1896–97, the rinderpest pandemic decimated “not less than 90 per cent of the enormous herds of the country’s cattle” (Bechuanaland Annual Report 1896–97). Rinderpest, which had the ability to hitchhike on humans and transport vehicles, nearly wiped out much of the ruminating livestock and wild ungulates, such as impalas (Marquardt, 2017; Molosiwa, 2014).

The decimation of wildlife frustrated the local peoples’ attempted recourse to communal hunting to stave off famine, thus contributing to dietary deficiencies and causing various human infections (Bechuanaland Protectorate Annual Reports, 1896–97; Molosiwa, 2014).

The ensuing hunger was further compounded by outbreaks of water-borne diseases, such as dysentery, on account of decomposing carcasses of animals that tainted local water supplies (Bechuanaland Protectorate Annual Reports, 1896–97; Botswana National Archives and Records Services, RC 3/2/1, 1896).

Right on the trail of rinderpest came the most devastating pandemic in modern human history, the 1918 flu pandemic (commonly known as Spanish flu), which swept across the globe in two waves. By the end of the year, this lethal pandemic had convulsed much of Southern Africa. It is estimated that the viral outbreak infected over a quarter of the world’s population, with the figure of 50 million being commonly accepted as an estimate of its death toll (Taubenberger & Morens, 2006). While hardly benign, its transmission between March and August 1918 was less lethal than what followed. By the end of the year, a more virulent, perhaps highly mutated, strain of the virus, whose advance was significantly speeded up by end of World War I troop movements, led to the vast majority of the pandemic’s regional, as well as worldwide, fatalities (Dehner & Phillips, 2020).

The Union of South Africa, with about half of its then approximately 6.7 million people afflicted, as well as a final death toll of up to 500,000, and whose statistics then included the High Commission territories of Basutoland, Bechuanaland Protectorate (Colonial Botswana), and Swaziland, was among the world’s most heavily hit jurisdictions (Phillips, 1990). In the Bechuanaland Protectorate (Botswana) human mortality was estimated to have reached 5% of the population (>Bechuanaland Annual Report, 1919).

Public health in Botswana continued, in later years, to suffer from additional diseases whose transmission was aggravated by labor migration. The period beginning in the late 1920s saw a spike in male labor migration from the numerous native reserves of the Bechuanaland Protectorate to the mines of South Africa (Morapedi, 1999; Schapera, 1947). With a large population of men engaged in temporary retreats between the mines in South Africa (where they worked) and their homes, the country faced imported public health threats.

Most of these men contracted new diseases at the mines, which they in turn transported back to their communities. In particular, infectious disease burdens continued to bear on the local population as epidemics of tuberculosis and syphilis concurrently caused massive public health shocks throughout the last half of the colonial period (Molosiwa, 2014, 2016a, 2016b).

The scourge of infectious diseases coincided with ecological shocks of severe and prolonged droughts, FMD, and locust infestations, which the country struggled to cope with and by the late 1960s these ecological shocks from the loss of many animal species had dramatically impacted food security and made local populations vulnerable to infectious disease (Hinchey, 1979; Peters, 1994). By the end of the 1970s, following independence in 1966, the postcolonial government had substantially reduced the country’s infectious disease burden, following measures that included massive immunization.

But the reprieve was short-lived as the 1990s began with the HIV/AIDS pandemic. Botswana has since had to cope with one of the world’s highest HIV infection rates for the past three decades, although with notable declines in national adult prevalence rates from 27% in the late 1990s to around 20% in 2020 (BAIS I-V 2001–2020; Kandala et al., 2012; World Bank, 2021).

This has been followed by yet another infectious disease challenge, that of COVID-19, necessitating the government to put innovative measures in place to deal with the crisis. These measures include the use of the hitherto existing zoonotic disease control zones, sanitization of people and vehicles crossing the zones, the quarantine/isolation, and the permit system, all of which have been used before in the control of FMD and the CBPP (Letshwenyo et al., 2004; Marobela-Raborokgwe, 2011). Historically one of Botswana’s primary economic interests has been the cattle industry and any health threat to this coveted resource has been aggressively combated.

The country has implemented stringent measures since the 1930s to combat the ubiquitous scourge that is FMD to protect national interests (Falconer, 1971; Molosiwa, 2007). While CBPP was successfully eradicated within 2 years of its outbreak in 1995, FMD has persisted as a health threat to the livestock industry to date. Unable to insulate itself effectively against the bio-threat that human and animal movement poses, the country has imposed and consistently maintained various stringent mechanisms aimed at detecting and containing zoonotic infectious diseases with the bid to avert any potential crisis.

Today Botswana boasts of a network of 13 veterinary cordon fences, with 9 main disease control zones forming important buffers against pathogens that may be transmitted by both humans and animals. These veterinary disease control zones have become very important in the control of the COVID-19 pandemic as they are used not only to restrict human movements, but also for disease surveillance purposes. As an integral part of the global village, Botswana’s persistent efforts at controlling infectious disease therefore emphasize its vulnerability to pandemics in an age of rapid travel and economic interdependence.

Research Origins

The research reported in this article was born in a familiarization tour made to the five regional campuses of the Botswana Open University from mid-to-late July 2020. The team on tour was made up of the co-authors of this article—an environmental health and technology specialist and chairperson of the University’s COVID-19 Task Force and a socio-environmental historian. The objectives of the expedition were to engage in academic interactions with staff at the regional campuses of the university and to check the COVID-19 compliance for prevention and control of the disease.

As we were traversing the boundary between the Francistown and Maun COVID-19 control zones, we were asked to stop the car, show our permits for travel and come out to sanitize our hands. Although this was the usual procedure known to all, the surprise came when we were also asked to step on a soaked pad on the ground to sanitize our shoes (Figure 2).

Figure 2.

Sanitizer-Dosed Floor Pads and Researchers Sanitizing Shoe Soles on These Pads When Crossing the Makalamabedi Disease Control Boundary (Then COVID-19 Zone Boundary) in Maun, Northwest Botswana.

This procedure was to prevent us from possibly transferring the coronavirus from one COVID-19 cordon belt (zone) to the other. The same procedure was done with shoes that we had in our luggage, as we were asked to bring them out to be sanitized. The surprise did not end there, as we were also asked to drive the car slowly through a shallow murky pond that we had thought was caused by rainfall. But this was not the case, as we soon learnt that the pond was also continually charged with sanitizer to disinfect the tires of cars that traversed from one zone to the other (Figure 3). Amazed by these measures, the title of this essay was born: “Sanitize the man, sanitize the car: COVID-19 disease control in Botswana.”

Figure 3.

Vehicle Being Sanitized as it Drives Through a Shallow Depression Dosed with Sanitizer, When Crossing from the Kuke Cordon Zone into Ghanzi, Western Botswana.

The main objective of this research is to discuss the attempts that have been made in Botswana to successfully control the COVID-19 pandemic. Successful past measures used for disease control, which have been applied for COVID-19, are also examined.

The Presidential COVID-19 Task Force

As soon as the COVID-19 pandemic was declared by the WHO in March 2020 and even before the first case was recorded in Botswana, a Presidential COVID-19 Task Force was established. Appointed to the Task Force were public health professionals and infectious disease experts as is normal globally with committees that deal with pandemics and epidemics. Unique, however, was the appointment of a former zoonotic disease specialist, Dr. Kereng Masupu, as coordinator of the Task Force. A seasoned epidemiologist and globally respected medical giant who has served this country and the region in many capacities, Dr. Masupu holds a veterinary medicine degree from the University of Tuskgee and a Master of Science in Epidemiology from the University of California. Dr. Masupu was the coordinator of the Task Force that contained an outbreak of one of the historic cattle plagues in the world, the CBPP, in the North-western Botswana in 1996 when he was a Deputy Director, Disease Control, Department of Animal Health and Production. Previously, Dr. Masupu served in various capacities within and without Botswana as a specialist in HIV/AIDS and tuberculosis. Being an epidemiologist with knowledge and experience in infectious human and animal diseases makes him the country’s top infectious disease expert, and very well qualified to lead the Presidential COVID-19 Task Force. The COVID-19 contagion has similar characteristics to that of CBPP, which Dr. Masupu helped to contain in the 1990s. Both are highly contagious, they target mainly the lungs and if not contained through restricted movement of carriers, they have great potential to spread exponentially.

Another member of the Task Force is Professor Mosepele as a deputy coordinator. Professor Mosepele is an associate professor of Medicine and Infectious Disease at the University of Botswana where he is also Head of the Department of Internal Medicine. He also holds research associateships with the Botswana Harvard Partnership and the Harvard School of Medicine. Next is Dr. Mogomotsi Matshaba, who is a scientific advisor to the Task Force and a pediatrician and assistant clinical professor of Paediatrics at Baylor College of Medicine and Retrovirology, as well as executive director of the Botswana-Baylor Children’s Clinical Centre of Excellence. Then comes Dr. Malaki Tshipiyagae, a surgeon, who at the time of appointment to the Task Force, served as a Director of Health Services. Dr. Tshipiyagae is, however, no longer with the Task Force since he has been replaced by the current Director of Health Services, Dr. Malebogo Kebabonye. The Task Force works closely and seamlessly with the Ministry of Health and Wellness.

Drawing on Prior Experience

At the onset of the pandemic Botswana’s response was swift. It immediately went into containment mode, most importantly with the express purpose of localizing the virus through movement restrictions. The containment strategy included first the demarcation of the country into disease control zones followed by the introduction of the permit system and the sanitization of people and their vehicles upon entry and departure from the disease control zones. While other containment measures, including social distancing, the national mask mandate, the quarantine and isolation of cases, have been equally effective, our interest is in movement restriction. The catalyst for this interest is Botswana’s experience in controlling pathogens, in this case zoonotic infectious diseases, which often spread easily with the movement of their hosts.

Disease Control Zones

Circular migration is deeply rooted in the livelihoods of the people of Botswana. Frequent movement between the urban areas and the countryside is a historical phenomenon that dates back to the colonial period and the advent of urbanization. For this reason, the outbreak of a pathogen that uses people as a host and therefore spreads quickly with the movement of people necessitates swift curtailment of frequent circular migrations, as shown in Figure 4. These are the boundaries of the COVID-19 control zones of Botswana.

Figure 4.

The COVID-19 Zonal Map of Botswana.

Like with the control of animal diseases, the Botswana Government borrowed from the old maxim, “prevention is better than cure” in its early reaction to COVID-19. The country was immediately demarcated into 9 COVID-19 zones with 13 entry points, where movement permits are required and sanitization and disinfection are carried out with an alcohol-based disinfectant.

This zoning policy imposes human movement controls between the zones. With these controls, the movement of people is only permitted under strict, designated conditions and when it is deemed safe to do so. Botswana’s proclamation of geographic areas as disease surveillance zones is anchored on the country’s historical experiences with FMD (1930 to the present) and the CBPP (1996–1998), both of which respectively forced the government to demarcate permanent disease control zones. Instead of re-demarcating the country, Botswana therefore used the hitherto existing zones because despite being driven by epidemiological imperatives, these zoonotic disease control zones are also determined by administrative boundaries and geographic barriers, which the migratory Batswana traverse with high frequency. It is interesting to note that the government is trusting local talent to develop and implement home-grown solutions to this global pandemic. The zonal restricted crossing approach is a model that most countries can learn from.

Sanitization

Globally, the word, “sanitization” has almost invariably become synonymous with the cleansing of hands with an alcohol-based hand sanitizer to kill the coronavirus since the outbreak of the COVID-19 pandemic. For Botswana, however, sanitization extends beyond cleansing human hands to include the disinfection of feet of both man and animals, vehicles and people’s personal belongings on transit, at the intersections of COVID-19 cordon belts (Figure 4).

This broadened form of sanitization is a re-appropriation of the hitherto existing practice of disinfecting people and their belongings at the veterinary disease control zones, which have temporarily been redefined as COVID-19 zones. Just like with sanitization for zoonotic disease controls, all humans who enter or exit the COVID-19 zones are required to leave their various forms of transport, walk to a sanitization point where they will sanitize their feet and belongings. Thereafter, the vehicle is driven through a pool of disinfectant to eliminate any traces of the pathogen. This practice of disinfecting tires and shoes proves to be effective, as, in an epidemiological sense, any surge of COVID-19 infection would be contained within the zone from where it emanates.

The Permit System

Following the implementation of the zoning policy, the country introduced movement permits, both intra-zonal and inter-zonal, for preventative and containment reasons. These, however, were stopped with the end of the state of public health emergency, which was introduced in early 2020 and ended in late 2021. The permits were official electronic and manual documents that authorized individuals to travel within and without all COVID-19 zones and they were mostly valid for only three days.

To obtain a travel permit, one had to submit an application through the Ministry of Health Wellness online application system. The applicant would receive approval (or rejection) through short message service (SMS) to their cell phones or manually through the District Commissioner’s office if they had submitted a manual application. Eventually, however, the Government of Botswana introduced an official digital contact tracing application called BSafe. This app recorded entry and exit of persons who had the application by way of scanning QR-codes. This app allowed individuals to check into registered facilities or businesses while allowing people to move within and across designated zones in the county.

However, the reliance on such technology was not beneficial to some people, especially the elderly, rural poor, and illiterate, where many do not even have cellphones. Also, some people, whether from rural or urban settings, display phobia with technology use and did not gain from such provision. Nevertheless, the manual permit system of data capture and control was still in place, to take care of such individuals.

The permits provided a surveillance technique that helped law enforcement and health authorities to track and control the flow of people and the spread of the virus. These movement permits were part of the successful legacy of zoonotic disease control previously used in the country. For the zoonotic diseases, such as FMD, veterinary authorities used the movement permits to track the movement of animals and therefore assisted in the surveillance of disease spread across the veterinary zones.

Herd Immunity

The drive to attain a herd immunity against COVID-19 is an important control measure (Agwanda et al., 2021), although new variants can result in repeat infections. Herd immunity is that situation where at least 70% of the population has acquired an immunity and become resistant to COVID-19, either naturally through recovery from the disease (natural herd immunity) or through the administration of vaccines (artificial herd immunity), is rife in Botswana. The latter is made recourse to, as trying to achieve herd immunity through the natural way will call for numerous unwanted deaths. Noteworthy also is that, with regard to the SARS-CoV-2 variants, exposure to one type may not provide strong protection against another. For example, many individuals who were infected by the Omicron variant had had a prior infection with another variant.

The country did very well on the vaccination front and, as of May 20, 2022, a total of around 3.2 million doses of vaccines have been administered. Around 87% of the eligible population (18+ years; 82% of entire population) had received their first vaccine doses, while around 77% were fully vaccinated. This compares favorably with neighboring countries like South Africa, a major trade partner of Botswana, where 59% of the population had received the first dose and around 33% fully vaccinated by late May 2022 (WHO, 2022). For Zimbabwe, another important neighbor to Botswana, the percentages are 70 and 27, respectively. It is important to bear in mind that vaccines and previous wild exposure can help prevent serious illness and reduce hospitalizations and deaths, but their effects in preventing infection is minimal. As the Botswana Government presses on to increase the vaccination coverage, people should continue to adhere to the public health and social measures (PHSM) and other controls (Agwanda et al., 2021).

The efforts made by Botswana are highly commendable, especially within the African context, as most countries have vaccinated proportions that are much lower. Adding to this effort, drive-through vaccination campaigns were launched from mid-October 2021 to help increase the pace and coverage.

Attainment of an artificial herd immunity has been the main target to eradicate the COVID-19 pandemic. The ideal situation, however, is for 100% of the population to be fully vaccinated. However, from 70%, things start getting good with the assumption that, by 70% vaccination of the people, 30% or so would have had artificial immunity through recovery from COVID-19, thereby making the entire population COVID-19 resistant. However, it should be noted that breakthrough infections are possible, that is, infection of those who are already fully vaccinated. This has especially been the case with the Omicron variant of SARS-CoV-2.

It must be noted here that at present, authoritative science and global talks point to the possibility that COVID-19 never goes away. It could be that it could shift to be highly contagious, endemic, but less deadly or there will only be sporadic peaks of infection occurring once in a while in different places, just as is the case with the seasonal flu.

Engendering a Disease Control Framework

In the face of COVID-19, the challenge posed on the global economy and public health has been enormous, with many countries struggling desperately to both prevent and contain the pandemic. A disease control framework, the combination of concerted steps taken to address the pandemic challenge and control the situation in Botswana, is highlighted here. It must be highlighted here that this innovative framework proposed is generic and can be used elsewhere for both similar and other diseases.

Botswana has made major strides in managing the pandemic, beginning with the Presidential Task Force that is the central command and information center, and is the advisory body to the President and Ministry of Health and Wellness. The accelerated drive to attain an artificial herd immunity through vaccination and keep COVID-19 under control has been quite effective, with the country sourcing vaccine doses from both the global COVAX/GAVI/WHO facilitation facility, a global effort to ensure acquisition and fair distribution of COVID-19 vaccines (although this has hardly been the case, e.g., see Pineo, 2021). The country also made direct acquisition of vaccines, since, unlike many other African countries, it did not qualify for subsidized vaccines under the COVAX scheme because it was classified as an upper middle-income country. This direct acquisition helped to reduce the risk of supply shortages. Also, this was necessary to reduce the risk of vaccine efficacy from new variants of the virus and the vaccine side effects,

Botswana used a diverse range of vaccines: AstraZeneca, Covishield (a variety of AstraZeneca), Sinovac, Pfizer, Moderna, and Johnson & Johnson. These vaccines are differentiated by the different technologies used in their manufacture and how they work. The viral vector ones use a safe virus that cannot cause disease but serves as a platform to produce coronavirus proteins to generate an immune response, for example, AstraZeneca and Johnson & Johnson. The messenger RNA vaccines use high level genetically engineered RNA that produces a protein that causes an immune response, for example, Pfizer and Moderna. The whole virus vaccines like Sinovac use a form of the virus that has been inactivated or weakened so it does not cause the disease, but still generates an immune response.

The government has made serious efforts to encourage citizens and residents to receive vaccine jabs, since herd immunity, without the unnecessary loss of life, will mainly be achieved through this means. It is encouraging to note that the vaccination rate in the country, that is, the number of people vaccinated per 100 has been rising, standing at around 62 per 100, as of mid-March 2022, compared to 39 per 100 in November 2021.

As part of the disease control framework, to be vaccinated, were urge to first register through the online platform: https://dhis2sms.gov.bw/vaccine/. The information collected through this registration process was used to facilitate:

Identification of eligible vaccination candidates

Planning the distribution of vaccines and other commodities

Allocation of candidates to their nearest vaccination sites

Communication with vaccination candidates about the COVID-19 vaccination program and their appointments

The vaccination process started in March 2021 and the prioritization has gone from the health workers and other frontline workers, the elderly and those who were unable to reach the designated vaccination centers, and advanced through the different age groups in the population.

The disease control zoning that Botswana has put in place has been in clear similitude with the days of controlling FMD. It has helped the country to limit the spread to small areas, thus increasing manageability. The permit system for control of movement that was instituted by the government required individuals to apply for permits before being allowed to travel within zones or cross zonal boundaries, buttressed this effort. The model should be kept on with and optimized by making sure that all the zoning belts and control points are very active, as this has not always been the case.

Keeping strictly to the public health protocols of effective mask use in well-ventilated spaces by all individuals, using sanitizer and washing hands, social distancing, avoiding crowds and unnecessary travel is still encouraged. In line with optimal risk management, extreme caution is recommended, with sanitizing of individuals and objects like cars (which can serve as fomites or inanimate objects that can carry the virus) at cordon belt boundaries has been stressed, as this helps in isolating pockets of infection so they do not to spread to other areas of the country.

The control framework must also focus on individual behavior as one of its ingredients, as SARS-CoV-2, the causative agent of COVID-19, is very opportunistic. Figure 5 presents a pyramid of three levels of disease control, applicable to the current COVID-19 pandemic.

Figure 5.

The Three Levels of Disease Prevention.

The present situation in Botswana directly applies to all these levels. The primary level involves everyone, where the behavior of individuals throughout the country is the main driver of the cases, leading to community transmission that has prevailed in the country. This has been well pointed out by WHO, which has related the expansion of cases in the country to be primarily from community transmission. Therefore, people need to be encouraged to tailor their behavior in terms of keeping strictly to the public health protocols of washing hands regularly with soap and water, sanitizing hands, keeping the required social distance of at least one meter, avoiding crowds, avoiding unnecessary travel, and staying in well-ventilated indoor spaces. It is, however, recognized that these PHSM are impossible for some segments of the population.

The secondary level links with the primary level, where behavioral patterns should be changed in communities as a whole, to reduce current cases. The tertiary level is where direct hospitalizations and other healthcare interventions are involved. Here, to break the cycle of the complications, intensity and severity of cases, the vaccination drive to attain a general herd immunity becomes crucial, as the vaccines prevent severe disease, reduce hospitalizations and deaths, and also reduce infection and curb transmission. The pyramidal continuum involves the preventative, curative, and rehabilitative levels of care, from the base to the apex of the pyramid.

The intermittent curfews that were put in place by the authorities in response to COVID-19 to control risks, with fines imposed on defaulters, helped a great deal, before the economy was fully opened at the beginning of October 2021. Every individual was also called upon to serve as a watchdog and report through the free call line, when someone behaved clumsily, as it was believed that COVID-19 could only be defeated in the country through a collective air-tight effort.

These efforts require the development of a strategic plan for the COVID-19 fight, with such a plan being monitored carefully and updated as necessary. Supervisors, together with their subordinates, must implement and roll out the plan and undertake intra-action reviews on a regular basis to identify gaps, lessons, and best practices (WHO, 2020), and to facilitate and improve the implementation of the overall plan.

Also, people have to be continuously made aware they should respond only to the information that comes from credible sources such as the Government of Botswana and the WHO. This is because people can easily be misled by misinformation and/or disinformation about COVID-19. Lockdowns to limit virus spread, have the negative side effects of creating stress on the economy and causing mental health problems such as depression, which need to be addressed in the planning and implementation of the COVID-19 response strategy.

Conclusion and Recommendations

The Government of Botswana has done and continues to do a commendable job to drive the country toward achieving herd immunity against COVID-19. The success has been brought by the quick acquisition of safe and effective vaccines, as Botswana was one of the first countries in Africa to procure vaccines. The success has also been due to the effective roll-out of immunization, together with the effective and efficient controls that were put in place. Also, vigorous campaigns to spread information on the importance of getting COVID-19 vaccine shots have helped significantly. In line with these, campaigns were the information, education, and communication materials that were developed and spread across the nation, together with the frequent updates that were given by the President on Botswana Television.

The country has been among the top African countries leading on the vaccination front. The zoning is very effective and should be continued in an optimized manner. To show its relevance, for example, on December 13, 2021, the zonal system created by the presidential COVID-19 task force showed a 7-day moving average of cases, with the middle belt and northern zones having fewer cases than the southern zones. However, the zoning has had to be optimized, as some zonal controls were found to be weak, and hardly had enough manpower.

The public health protocols are still being followed, especially as different SARS-CoV-2 variants are still propagating around the globe. Sanitizing of individuals and objects like vehicles at cordon belt boundaries has helped control the virus, and any future pandemic can be proactively tackled by using this again. Such practices have been carried over from the successful control of FMD that plagued the country previously.

A layered approach of preventing and controlling COVID-19 is required, and necessitates a mixture of methods. This has been enhanced by the development of a strategic plan for the COVID-19 fight, including when the pandemic shifts to endemicity. Implementation of the plan has been monitored carefully and updated as necessary. Indeed, these measures which have been used in Botswana can and should be employed elsewhere to control infectious diseases such as COVID-19.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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