The COVID-19 pandemic has shown stark divisions between medical professionals, on the one side, and bureaucrats and politicians on the other, writes MedicalBrief. Following the national Health Department's recent demand for an official investigation into critical comments by a leading scientist, North West Health has now unleashed a new row with its surprise suspension of the head of internal medicine at a Klerksdorp hospital, drawing condemnation in the form of an open letter signed by more than 250 doctors and researchers.
They write: “Without warning, Professor Ebrahim Variava was yesterday suspended from his post of head of internal medicine at the Tshepong public sector hospital in Klerksdorp where he has worked tirelessly for the past 20 years. This has shocked his work, clinical, teaching and research colleagues.
“His suspension comes at a time of National Disaster when medical professionals, particularly those expert in the diagnosis and treatment of patients with severe medical illness, are most required to treat patients with COVID-19. During his tenure at the hospital Professor Variava has built a superb academic department in an underserved province that trains medical students and specialists and conducts cutting-edge research into HIV and TB.
“In North West Province, almost all COVID-19 patients are admitted to the internal medicine department at Tshepong Hospital. It is extremely worrying that at the precise time when the epidemic is rapidly rising, the leader of this department has been suspended. The best interests of patients, the hospital, and its community are clearly not served by the suspension of Professor Variava.
“We, therefore, call on the North West Province to immediately withdraw his suspension, and urgently establish a constructive dialogue to resolve their differences without putting any patients at risk.
Separately, concern also resurfaced this week over the national Health Department's failure to follow the advice of the medical scientists that serve on its Ministerial Advisory Committee (MAC). At least three top scientists have said publicly that they cannot fathom why health authorities are sticking to a testing strategy that is not producing the necessary results.
A few weeks ago, there was a public row when the SA Medical Research Council instituted, at government request, what the Academy of Science of SA described as an “impulsive and high-handed” investigation into Professor Glenda Gray, MRC president and ministerial adviser on COVID-19, over comments she made in her personal capacity about the government’s handling of the pandemic. In the face of a national outcry, the MRC quickly exonerated Gray.
This week, reports News24, Professor Francois Venter, head of the Ezintsha health unit at the University of the Witwatersrand and a member of the MAC, says he and other scientists cannot fathom why health authorities are sticking to a testing strategy which is not producing the necessary results.
According to the report, Health Minister Zweli Mkhize said that the Health Department adopt a more focused testing strategy, which would involve prioritising infection hotspots. But this is not the same as what has previously been recommended to him publicly by Venter and others. Crucially, it does not involve getting rid of the testing backlog samples, which Venter and others say is crucial to freeing up much-needed capacity in the country's laboratories.
Until now, the COVID-19 strategy involves testing patients referred from a mass screening programme, which has seen more than 180,000 people referred for COVID-19 tests so far. According to Mkhize, this has enabled the department to identify hotspots which would now be targeted with more resources, including priority testing.
But Venter and others have for weeks argued that, due to severe resource constraints, leading to low turnaround times from sample collection to results, tests should be reserved for hospitalised patients and healthcare workers.
According to the National Institute for Communicable Diseases (NICD), the average turnaround time for tests is now around nine days, up from two days in April. "The turnaround times (for tests) remain a disaster. We (scientists) have told them repeatedly to throw away the medical waste and prioritise. We've been saying this for weeks," Venter is quoted in News24 as saying.
Two other members of the MAC supported Venter's sentiments this week: Dr Jeremy Nel, head of infectious diseases at Helen Joseph Hospital, said the testing strategy "is not moving fast enough in the right direction", while Professor Shabir Madhi, newly appointed dean of the health faculty at Wits, confirmed that "a prioritised approach was recommended to the minister".
Venter, Nel and Madhi, however, said they could not comment on what took place at MAC meetings as these were confidential.
The state laboratory has dramatically improved the turnaround time for COVID-19 tests from the Western Cape and the province’s backlog should be cleared by the end of the week, the provincial head of health is quoted in Business Day as saying. The development is important because the Western Cape currently bears the brunt of South Africa’s COVID-19 epidemic, accounting for 65% of the more than 36,000 cases reported to date.
Extensive delays in getting results from the National Health Laboratory Service (NHLS), which were partly due to problems sourcing test kits and reagents from international suppliers, prompted the provincial health department to turn to private laboratories for help and to ration tests.
Last week it announced that tests were to be prioritised for patients admitted to hospital, healthcare workers, people with co-morbidities and those over the age of 55.
The report says increased capacity at the NHLS, combined with a decision to prioritise Western Cape specimens, had seen its backlog whittled down from approximately 27,000 two weeks ago to 3,727 on Wednesday of last week, said Western Cape Health head Keith Cloete.
The turnaround time for tests for hospital patients has been reduced from as long as five days to within 24 hours, and some patients are now getting their results on the same day they are tested, he said.
"As of 8 June 2020, the NHLS has conducted 492,704 tests," News24 reports NHLS CEO Kamy Chetty told the MPs. She said the NHLS has increased the number of tests done each month with a massive increase in the number of tests being performed during the month of May, where the figures more than doubled between April and May.
In the first week of June, 105,023 tests were done. This is already almost half of the 232,862 tests that were done in the whole of May and more than April's 94,203 tests. In March, 6,341 tests were done and, in February, 276.
A reasonable time to clear a sample through the laboratory, if all test kits and resources are available, is 48 to 72 hours. The report says while the NHLS' machinery gives it the capacity to do 35,000 tests a day, it only does about 10 ,000 because of the availability of the test kits.
Chetty said each person who is tested is advised to self-isolate for 14 days, which should prevent people from spreading the disease. Therefore, the backlog itself shouldn't be affecting people's behaviour.
She said the specimens were stored under very specific conditions, so there shouldn't be any contamination.
Professor Wolfgang Preiser, the head of division of medical virology at the department of pathology at the University of Stellenbosch says that testing of people previously diagnosed for COVID-19 to ensure they are no longer infectious before returning to work is "nonsense and must stop", reports News24. Preiser, also a member of MAC, said he could not divulge details of the MAC meetings, but added he could comment on issues that were public knowledge.
Preiser said: "Going forward, it will be vital to avoid testing patients that do not fulfil the criteria or, even worse, people who are not patients, for example, those who may have been exposed and need to be quarantined."
"Here, a single test on day eight after last exposure to (COVID-19) can be done for essential workers like healthcare staff; if negative, the individual has very likely not been infected and can return to work, instead of waiting a full two weeks (before returning to work); the five or six days saved (by returning to work) are important for highly needed professions.
"Testing of people previously diagnosed as infected, for example before they are allowed back to work, is nonsense and must stop; in uncomplicated cases, two weeks after [the] onset of illness and, in more severe cases, two weeks after coming off oxygen support is sufficient waiting time to make sure the individual is no longer infectious.
"Any testing in this context is unnecessary and wasteful. We have to make sure that tests are used only for those who will benefit from results, and then that they are done as quickly as possible."
Preiser said it was improving in the Western Cape, that urgent cases were being prioritised, although it was "debatable" whether all the samples in the backlog should be tested.
"We are well on our way to clear the so-called backlog here in the Western Cape; the backlog are samples that could not be tested at the time due to various reasons (mainly problems with getting test supplies, which is a problem globally).
"Whether this belated testing is still needed at all is debatable, but we do it while prioritising current specimens (which are urgent so that patients can be managed appropriately) so it does not compete with urgent work," he added.
Preiser said, as part of the Western Cape's recently adopted targeted testing approach, patients suspected of having COVID-19 were not tested if they were younger than 55 and did not have risk factors for severe illnesses. They are advised to self-isolate at home and be vigilant for danger signs their condition is deteriorating.
News24 quotes Mkhize as saying the issue of the disposal of samples in the backlog was complex. "Some people were saying, oh, you need to discard them (the samples) after 14 days; others were saying after four days, others were saying after two days. We have asked the question, what is the basis for that? One argument was, we are wasting resources on the people who have not been tested that are in the backlog.”
Preiser said turnaround tests were not always a good measure to use when assessing the state of the COVID-19 response. "These averages do not reveal the extremes, nor the spread. For example, while we may have had a few thousand samples a week old or older that yet had to be tested, we were testing others within 24 hours or even within two to three hours if highly urgent.
"The average may have looked bad, the reality on the ground was that we were providing a good service for current patients while we had failed some patients earlier; those who needed a test result that was not forthcoming often had subsequent sample sent as urgent which allowed appropriate clinical management," he added.
Nel said in the report that the delayed turnaround time for tests was "not just an irritation. It has several profoundly negative consequences in the healthcare system, including: having to open up new wards and beds within the hospital for patients who are awaiting their test results; having to use extra personal protective equipment and other consumables while awaiting test results; exposing staff unnecessarily to potentially infectious patients since more wards are necessary to keep patients who are awaiting results; potentially delaying important decisions about who should be ventilated or sent to ICU until results are available."
He said the delayed results also made making hospital outbreak investigations almost futile. "(Because) if results take several days to come back, the patient or healthcare worker may have infected several other people in the intervening time."
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