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Lockdown must go or else non-coronavirus mortality will outstrip COVID-19 deaths

While the lockdown bought some time to bolster health resources, it has is now setting up South Africa for even greater mortality from non-COVID illnesses, said infectious disease expert and former head of the National Institute of Communicable Diseases, Professor Shabir Madhi, in a Daily Maverick webinar.

Madhi, a member of the Ministerial Advisory Committee on Health was speaking with Maverick Citizen editor Mark Heywood.

While the lockdown has bought time for South Africa’s health system to prepare, wrong timing, a lack of testing, the wrong type of testing and the slow release of results had snatched away government’s chances to significantly slow community infections, Madhi said.

Instead, the continued strategy is causing more harm as people are battling to access basic medical tests for South Africa’s biggest killer, TB. Hospitals are starting to see cases of malnutrition and children’s futures are being placed in jeopardy by keeping the schools closed.

Referring to the collateral damage caused by the ongoing lockdown, Madhi said the current government response was “setting us up for greater mortality from non-Covid related illnesses”. As an example, he mentioned that there had been a 50% reduction in tests for TB and a delayed diagnosis. TB remains the leading cause of death in South Africa.

He said by imposing lockdown before South Africa was ready to do mass testing, the country’s chances to fight the spread of community transmission had been damaged, and further harmed by continuing with an unsustainable test-and-trace strategy as test results take up to two weeks to be released, allowing the number of contacts that must be traced to skyrocket and creating impossible workloads for health workers as cases hit 10,000.

“The only thing that is going to help us is for the citizens to take responsibility. Government can come with every policy in the world. If citizens are not going to take responsibility, we are going to fail,” Madhi said.

But Madhi said what the lockdown had not done and what no future intervention is going to do, is to reduce the number of people who will be infected in South Africa. “Be it over a six-month period, be it over a two-year period, this infection is going to be with us at least until 2021 or 2022,” he said.

“A lockdown is not a magic bullet… unless citizens take collective responsibility, there isn’t anything that government can do… If citizens don’t do what they are requested to be doing… we will have a quicker transmission and a greater peak,” he said. It was time to open schools while observing preventative measures like personal distancing, hand hygiene and wearing masks and phase in classes. 

“Children are being punished for a problem that they are not [creating]. They are not the vectors of spreading the disease. The transmission is not the same. What is the trade-off of putting their future in jeopardy?” he asked.

He said while lockdown has served its purpose, the government should rather focus on obtaining the buy-in of communities.

“Collective responsibility will be key. But we need to guard against the collateral damage that is being done [by lockdown].  Children are not being vaccinated. People are not being diagnosed with TB. There are cases of children developing malnutrition,” he said.

“What we know about Covid-19 in children is that they rarely develop a severe illness. As an example, in Italy there were 30,000 deaths from Covid-19, of which none were children younger than 18. In the United States, less than 2% of cases were children and only three died. All three had underlying medical conditions.

“For the first time that I have come across in 25 years of studying respiratory pathogens, children are being spared severe disease from a respiratory virus. We don’t fully understand the reason… but worldwide only a handful of kids died of Covid-19.  The other concern is that children can be an important vector of transmission – but it was an extrapolation of what we know about influenza as we experience it every year.”

He said a study from the Netherlands and another done in Australia showed that there were hardly any cases of children infecting adults.

He added that lockdown was not a sustainable strategy to fight the pandemic. “We are looking at three to four waves of infections. We must plan. That is the message that needs to sink in. Roughly 60% of SA will get infected irrespective of what we do before we develop herd immunity,” he said.

This, Madhi was at pains to point out, was not a doomsday scenario, as 70% of those infected will be asymptomatic, 25 to 26 out of 1,000 will need to be hospitalised and three to four people unfortunately might die. Of these, he added, 90% will be older than 65 with co-morbidities.

“I am not saying that we should not have gone into lockdown. The timing of the lockdown, in relation to what should be the main purpose of the lockdown (containing community transmission), was not correct… Had our testing capacity been intact and if we had the right criteria of who should be tested, we would have been more successful to identify infected individuals and prevent transmission,” he said.

“The main reason why the lockdown was important was that health facilities were not ready. It bought them time to prepare bed capacity, oxygen points, personal protective equipment and so on. We can sort of tick this one [off] because we are not too sure exactly what is going to come our way. But as far as you can achieve over a three to five-week period. You do not build health systems in three to five weeks. It probably required much more time for health facilities to equip themselves to deal with what is going to be an inevitable issue that there is going to be a surge of cases,” he said.

He said that carrying on with lockdown as a way to deal with community transmissions won’t be successful.

“Interrupting the rate of community transmission is not the same as eliminating the virus. In the whole history of mankind we have only been successful ever in eradicating one virus and that was smallpox. We accomplished this through vaccination.” 

He said no respiratory virus had ever been eliminated completely.

He added that before lockdown, less than 20% of infected people’s contacts were traced. 

“The modelling data shows that to curtail the transmission of the virus at an early stage you have to be effective at tracing 80% of the contacts. If you are not able to trace 80% of contacts, you will not be able to control the spread of the virus,” he said.

“The reality of what is happening right now is that it takes between five and 14 days for test results to come back. If we can’t get a result back within 12 to 24 hours those tests are meaningless. The most important metric should be how many of these tests are coming back within 24 hours; how many contacts are identified and what percentage were traced and tested and put in isolation and quarantine. This is a mammoth task. It works at the start of a pandemic when there are few cases. You reach a tipping point when it becomes implausible,” he said.

“There was a belief that we could have interrupted community transmission through lockdown. We cannot do this, but there was a perception that this was the purpose of the lockdown. This is not about interrupting community transmission. Each year we have influenza and other viruses. You cannot interrupt them.  You can try to reduce the rate of transmission. We did reduce community transmission, there was some reduction, even though the exact nature is difficult to quantify. It is difficult to quantify because the number of tests dropped in the first two weeks of lockdown.” 

Madhi explained that during the first two weeks of lockdown the number of tests decreased to less than 1,000 a day countrywide. Before lockdown was imposed between 2,000 and 3,000 tests were done, Madhi said. He added that there was a drop in cases because of a drop in tests but also because cases were in the incubation period.

He said towards the end of the hard lockdown period (that ended on April 30) there was a tenfold increase in the number of tests and then about 400 new cases a day were being diagnosed. “If you test more, then you are going to find more cases.”

He said, in his opinion, it would be more important to limit tests to those in hospitals to protect health workers and provide doctors with the best treatment strategy – and make sure these are available within a day. Instead, he added, rapid antibody tests should be implemented to do community testing and identify hotspots.

He questioned the wisdom of the current government strategy using health workers to do household visits and screen individuals. 

“The reason why no other country in the world does this is that we are talking about a respiratory virus. People can develop symptoms of the virus the next day. The strategy is fundamentally flawed. We need better access for testing facilities in the communities. If we are serious about identifying this – our window of opportunity is closing in on us, if it hadn’t passed us by already.

“I am not saying, throw community testing out of the window – the testing available in the country does not lend itself to what we are setting out to do. With a rapid antibody test you can map how an epidemic is evolving. We must change strategy.

Writing in The Conversation, two leading experts say that the COVID-19 epidemic in South Africa is now in its exponential phase and a change in strategy is necessary: Stop the testing and contact tracing components of the community surveillance programme, in favour of self-reporting of symptoms via an app-based programme on mobile phones.

Marc Mendelson, professor of infectious diseases, at the University of Cape Town and Shabir Madhi, professor of vaccinology and director of the MRC Respiratory and Meningeal Pathogens Research Unit at the University of the Witwatersrand write:

The COVID-19 epidemic in South Africa is now in its exponential phase. Cases are rapidly increasing in many areas. This is most apparent in the Western Cape province, which could be due to higher rates of testing per capita, coupled with a more selective testing strategy than in other provinces. The doubling time of mortality in the province’s Cape Town metro is now 8-9 days, indicating a rapid increase in the number of severe cases and deaths from COVID-19. Although the health system is better prepared as a result of the initial lockdown, major cracks are starting to show. This is causing a deterioration in clinical service which, if not stemmed, threatens the country’s response to the epidemic.

Globally, rates of testing for SARS-CoV-2 infection have varied between and within countries. For example, testing rates (per 1,000 people) range from 148 in Iceland to 0.76 in India. In South Africa, as of 3 May 2020, the testing rate was 4.5. The high demand globally for molecular assays (known as PCR) to identify infectious cases has led to a shortage of samples and kits required in laboratories.

In South Africa’s case, the rise in the number of cases in the Western Cape, and the pressure this is putting on laboratories charged with processing tests, is only the forerunner. Here, we explain what needs to be done, and why.

Turnaround time
Diagnosis of COVID-19 relies on a laboratory test that is simple, but laborious. The time taken from the sample being taken to communication of the result – the “turnaround time” – is influenced by a number of factors. These include the speed at which the sample reaches the lab, the lab’s capacity to run the test – access to reagents and test kits, number of analysis machines, availability of staff, errors leading to a need for re-testing – and the communication process.

Early reports by the National Health Laboratory Service indicated that it had the capacity to do 36,000 tests a day by the end of April 2020. But capability to do so has not materialised.

Currently, the number of tests received in laboratories exceeds their capacity to deliver results within 12-24 hours of sampling. In many parts of the country, turnaround time has increased from 24 hours to over 5-14 days. According to correspondence we have seen, some labs with the capacity to do 1,000 tests a day have a backlog of 10,000.

Why “turnaround time” is so critical
South Africa’s ambitious community testing programme relies on identifying infected persons, isolating them, tracing their contacts, and isolating or quarantining them. Identification of infectious cases – even if only a quarter of those who are infected are identified – coupled with adequate tracing of their contacts and ensuring isolation (of cases) and quarantine (for up to 14 days) of test-negative contacts, could assist in slowing the rate of community transmission of the virus.

This would mitigate the expected surge in severe COVID-19 cases occurring over a very short period of time. Healthcare facilities could be better equipped to deal with the expected surge of COVID-19 cases over the next 2-3 months.

But for such a strategy to be effective requires a clear line of sight in terms of efficiency of testing, isolation of cases as quickly as possible (within 12-24 hours of being tested), and effective and immediate tracing of their close contacts.

It is estimated that any single case will, on average, have 20 close contacts (probably higher in South Africa) who should be traced. These include any close contacts (someone who spends more than 15-30 minutes within 1.5 metres of the person) occurring from at least 2-3 days prior to symptom onset in the identified case, and up until the case has been isolated. Assuming that isolation occurs on the third day after symptoms appear, for each case there would be approximately 120 close contacts to be followed up.

For this strategy to assist with slowing the spread of the virus requires tracing (and physical contact for screening for symptoms) of approximately 80%. Although possibly achievable in the initial phase of the epidemic, it becomes an unrealistic goal to aspire to when identifying 400 “new cases” each day, as that would require tracking and physical tracing of approximately 5,200 contacts.

This is why the turnaround time matters. A delay means that the current “new” cases reported in South Africa reflect cases that were likely sampled approximately a week ago.

This points to the need to shift the focus of PCR testing to patients being admitted to the hospitals. This would inform the management of the patient and limit the likelihood of spread within hospitals.

But the turnaround time for this cannot be anything more than 12-24 hours if it is to achieve any of these goals of testing. When a person with COVID-19 is admitted to a hospital, it is critical that they do not infect others. We achieve this by triaging patients into those who are COVID-19 suspects (a “person under investigation”) and those who are not. We separate patients into different wards accordingly.

Slow turnaround time for tests means a delay in diagnosis. The longer the turnaround time, the worse it gets. As the epidemic accelerates in South Africa, the number of patients needing to be admitted to hospital as a “person under investigation” and subsequently COVID-19-confirmed cases rapidly rises, and the system becomes overwhelmed. This is why we are arguing for a wholesale change to the current system.

How to fix the faults
We believe the following crucial steps need to be introduced as a matter of urgency. Stop the testing and contact tracing components of the community surveillance programme, in favour of self-reporting of symptoms via an app-based programme on mobile phones. We believe there is sufficient mobile coverage and access to do this. This would allow monitoring of disease activity, and self-isolation of symptomatic people for 14 days on the probability of COVID-19 infection. If resources allow for testing to confirm negative status sooner than 14 days to accelerate early return to work, that should be considered, but not at the expense of undermining turnaround times in hospitalised patients.

Steps need to be taken to map the spread of SARS-CoV-2 in communities. This should be done by gathering evidence on the seroprevalence, which can be measured using rapid antibody blood tests to detect recent or past SARS-CoV-2 infection (but not whether currently infectious). Geospatial mapping of the epidemic could assist in a more measured and informed approach for developing district or regional strategies to reduce the rate of community transmission. It could also help inform anticipated demands on healthcare services.

Focus testing resources on specific groups of people for whom a rapid turnaround time result will effect significant change.

Allow rapid diagnosis of hospitalised people under investigation, which allows optimal case management of severe COVID-19, optimal infection prevention and control, and patient flow to enable hospitals to cope with the escalating numbers as we climb the exponential curve to the peak.

Rapidly isolate and quarantine symptomatic healthcare workers and their close contacts to limit hospital outbreaks.

Introduce high risk group surveillance and testing, including patients and staff at long-term care facilities.

Convene an intersectoral government task force to analyse the barriers to operational flow of the entire testing system and make recommendations for a new testing strategy.

[link url="https://theconversation.com/south-africas-covid-19-testing-strategy-needs-urgent-fixing-heres-how-to-do-it-138225"]Full report in The Conversation[/link]

[link url="https://www.dailymaverick.co.za/article/2020-05-11-flawed-lockdown-has-served-its-purpose-and-should-be-discontinued/?utm_medium=email&utm_campaign=First%20Thing%20Monday%2011%20May%202020%20Investec%20AM&utm_content=First%20Thing%20Monday%2011%20May%202020%20Investec%20AM+CID_1e9e2543280b8fd011740bc8ad1b3a76&utm_source=TouchBasePro&utm_term=Flawed%20lockdown%20has%20served%20its%20purpose%20and%20should%20be%20discontinued"]Full Daily Maverick report[/link]

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