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COVID-19: SA 'would struggle' because of specialist shortage

Despite only one person in Africa so far diagnosed with Covid-19, experts warn of the potential for imminent havoc on an under-prepared, under-resourced continent, writes MedicalBrief. In South Africa, specifically, the acute shortage of infectious disease specialists in both public and private hospitals means the country would struggle to contain an outbreak.

Bill Gates has warned that coronavirus in Africa could overwhelm health services and trigger a pandemic which could cause 10m deaths. The Daily Telegraph reports that the Microsoft founder and global health pioneer was speaking at the AAAS meeting in Seattle just hours before the first case was confirmed in Cairo, Egypt. There are now fears that the disease could spread to sub-Saharan Africa where it could spark an uncontrollable outbreak, with health services unable to monitor or control the virus.

Gates said: “This is a huge challenge, we’ve always known the potential for a naturally caused, or intentionally caused, pandemic is one if the few things that could disrupt health systems and economies and cause more than 10m excess deaths. We’re doing the constant science to provide the tools to do the diagnosis to provide vaccines, to provide therapeutics and hopefully contain this epidemic, but it’s potentially a very bad situation.”

Gates warned that there had been a huge under-investment in anti-virals and called on China to "step-up" and provide better drugs.

According to the report UK experts said it was unsurprising that the disease had reached Egypt because Cairo was a world hub and had a lot of visitors from China. They said it was encouraging that the Africa Centres for Disease Control and Prevention (Africa CDC) were working with the World Health Organisation (WHO) and African Member States to improve diagnosis and surveillance. The patient was isolated quickly and people who had been in contact all tested negative.

However, the report says, other experts warned that the limited health services in Africa may mean it is already in other countries undetected. Dr Andrew Freedman, Reader in infectious diseases and honorary consultant physician, Cardiff University School of Medicine, said: “It was always inevitable that the virus would spread to the African continent. “Indeed, there may well already be more cases in other African countries that have evaded detection.”

The wildfire spread of the coronavirus from China’s Hubei province to 28 other countries suggests it is just a matter of time before it arrives in South Africa. According to a Business Day report, the big question confronting South Africa is whether health authorities will be able to detect and isolate patients fast enough to contain the virus, or whether the worst-case scenario will unfold, with extensive transmission within communities.

The report says the Health Department has been scaling up its capacity to detect and manage Covid-19, including increasing personnel at ports of entry, screening incoming travellers, and designating public hospitals in each province for potential cases. Behind the scenes officials are talking to the private hospital sector about how they will co-operate should the need arise, as private hospitals have lower bed occupancy rates than those in the state sector.

The National Health Laboratory Service is conducting all testing for suspected Covid-19 cases, but provincial laboratories were asked last week to submit their requirements to take on some of the load, and private laboratories are stocking up on test kits. The report says these are all reassuring moves, but they do not address fundamental weaknesses in the country’s health system highlighted by the global health security index, which scores countries out of 100 based on their capacity to cope with a health emergency such as Covid-19.

The report says South Africa’s experience with the novel H1N1 influenza in 2009 offers a hint of the kinds of problems that could accompany an extensive coronavirus outbreak. While it reflects well on the provincial health system’s capacity to manage H1N1 at the time, it illustrates the immediate knock-on effect for other patients who are crowded out by the acutely ill.

Red flags about a local shortage of infectious disease specialists have raised fears that South Africa may struggle. Though TB is the country’s biggest killer and antibiotic resistance and hospital-acquired infections are common in public and private hospitals, the Financial Mail reports that the speciality best equipped to deal with this has the fewest training posts funded by the government.

A letter to the SA Medical Journal in September last year, signed by 79 leading experts in the field of infectious diseases, warns that the specialty of infectious diseases (ID) is in crisis in South Africa.

"Despite the enormous burden of infectious disease, there are fewer trained specialists than in any other major discipline, and a shortage of training posts means that this is unlikely to reverse in the near future. It is vital that the National Department of Health recognises this, and the crucial role that ID specialists play, first and foremost in caring for patients, training cadres of staff, directing infection-related research, and shaping important health policy decisions for the country and its provinces.

"This must be coupled with immediate attention to providing an increase in specialist training posts, and positions in the public sector for those completing training. The number of ID specialists must mirror the burden of infectious diseases in SA, so as to deliver the service provision SA needs."

Tom Boyles, president of the Infectious Diseases Society of Southern Africa, is quoted in the Financial Mail report as saying only nine infectious disease specialists are in training in South Africa currently, "a trivial number compared to the burden of disease and the number of trainees in other specialties". He says: "When the virus hit the headlines the first people who were asked to help were infectious disease consultants, along with the NICD." The problem is that only five provinces have tertiary hospitals with infectious disease consultants. The others have none.

And, the report says, private hospitals have fewer infectious-disease specialists. "Ironically, it could be the private sector that is most affected by the lack of infectious disease consultants. At least initially, cases are likely to arrive on international flights and patients are therefore more likely to use private hospitals. While some infectious disease consultants have been forced into the private sector due to the lack of posts in the public sector, they are still a relatively small number," says Boyles.

[link url="https://www.telegraph.co.uk/news/2020/02/15/coronovirus-bill-gates-warns-10-million-deaths-virus-spreads/?li_source=LI&li_medium=li-recommendation-widget"]Full report in The Daily Telegraph[/link]

[link url="https://www.businesslive.co.za/bd/national/2020-02-17-news-analysis-coronavirus-would-wreak-havoc-on-sas-public-health-system/?utm_source=&utm_medium=email&utm_campaign=Discovery+loses+appeal+on+basic-care+benefits+%7C+Gwede+Mantashe+will+not+commit+to+renewable+energy+time+frame+%7C+Coronavirus+would+wreak+havoc+on+SA%E2%80%99s+public+health+system&utm_term=http%3A%2F%2Fwww.businesslive.co.za%2Fbd%2Fnational%2F2020-02-17-news-analysis-coronavirus-would-wreak-havoc-on-sas-public-health-system%2F"]Full Business Day report[/link]

[link url="https://www.businesslive.co.za/fm/fm-fox/2020-02-13-coronavirus-red-flags-over-shortage-of-sa-specialists/"]Full Financial Mail report[/link]

[link url="http://www.samj.org.za/index.php/samj/article/view/12699/8952"]SAMJ correspondence: The infectious diseases specialty in SA is in crisis[/link]

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