(Photo: Unsplash/Mélissa Jeanty)
Tonight South Africa begins a 21-day lockdown. While there is unanimous support for the necessity of such a drastic measure it is important to keep level heads; it is also important for the President and the National Command team to be open to constructive suggestions that aim to make sure that the lockdown succeeds in its aim of ‘flattening the curve’ and drastically reducing the incidence of new infections. This article, based on conversations with leading public health experts in South Africa and internationally, must be read in this spirit.
The lockdown being entered into in South Africa does not yet fulfil the conditions recommended by the head of the WHO leading the global response, as well as other leading scientists including 2013 Nobel Prize winner for Chemistry winner Michael Levitt.
In particular, it is important to know that the only countries where a lockdown has been successful in containing the epidemic is where it has been coupled with widespread community-based testing of symptomatic individuals throughout society, followed by their isolation in dedicated facilities if required (as is the case in SA), as well as the tracing of their contacts and the systematic follow-up.
In the absence of this system being in place, modelling data in fact shows that a lockdown is unlikely to yield any inroads in interrupting the epidemic.
Up to now, the Achilles’ heel in the response is the failure of the National Health Laboratory Services (NHLS) management to have ensured that it has adequate capacity to test samples at scale. This lack of planning is exacerbated by the shortage now being faced across South Africa in the availability of consumables necessary for the testing, let alone for the tests to be done. This requires intervention at the highest level and NHLS needs to partner with other capable groups, including laboratories in academia who are willing to help but are not yet being roped in, to enable an immediate scaling up of laboratory testing capacity within the next 72 hours.
It is an open secret that for a long time the NHLS has been plagued by corruption and mismanagement which has at times threatened delivery of vital pathology services. Although, thankfully, the NHLS is being cleaned up, we are aware that tensions remain. It is to be hoped that the national interest is the only factor now influencing programme development. That is why it is crucial that oversight of scaled-up testing for Covid-19 should be directly managed, without any hindrance, by the National Priority Programme (NPP) at NHLS. In this programme we have world-class experts who have direct experience in being able to scale-up testing for HIV and Tuberculosis (TB) at a huge scale. However, the NPP must also ensure inclusion of other partners from the private sector and academia to maximise capacity. This should be planned at a provincial level for districts and localities that are identified as hotspots of Covid-19 transmission.
Communicable disease experts agree that the key steps for a lockdown to work in stopping transmission and thereby “flattening the curve” is addressing the questions of who to test, when to test, why the testing is being done and how to respond to the test results.
In this respect, at the minimum, the following needs to be implemented immediately:
- Immediate measures to procure the necessary material for testing to be undertaken, from swabs to transport media and reagents for testing.
- All hospitalisation for acute pneumonia at any hospital needs to be treated as a suspected case of Covid-19 and managed accordingly, including investigating for SARS-CoV-2. This will at the least identify the hospitalised cases, which will serve as an index for the extent of community transmission (which is still a major unknown). Also, it will enable adequate measures in terms of isolation and lessen the risk to healthcare workers who could be inadvertently infected if they do not know the patients’ status.
- For the lockdown to be successful, requires the identification of cases in the community and plans on how to isolate them, as well as immediate tracing of all their contacts, and their quarantine (ideally in dedicated facilities). This is especially necessary in the South African context of overcrowding in the same dwelling and close proximity to neighbours. There needs to be immediate identification of facilities, including use of schools, University residences, etc for this to be actioned. If this cannot be achieved the World Health Organisation (WHO) and other leading scientists indicate that the lockdown is unlikely to be successful once there is community transmission, as is currently evident from the sporadic cases reported in non-travellers.
- Immediate rollout of mobile or drive through type of facilities for testing to be undertaken and adoption of the latest available technology to assist with reporting of results, tracing of contacts and monitoring of contacts (people under quarantine). The extent of the outbreak does not lend itself to individual level assessment at scale.
- Call upon skilled personnel at academic institutions, especially in Gauteng, Western Cape and KwaZulu-Natal, which have clearly emerged as the hotspots, to be at the forefront of spearheading the community-based testing programme. This has to move away from Provinces that are completely overwhelmed, do not have the expertise (as evident from only 20% of contacts currently being traced at all). This entire function is now beyond any central control by any one structure.
- Ensure that other aspects of the health system, including immunization services for influenza, TB testing etc are not compromised, as the collateral mortality in doing so could far exceed any benefits of the lockdown.
- Following a principle established and implemented in the response to the AIDS epidemic the current scientific advisory group to the Minister of Health needs to include civil society, who can assist with mobilisation, community preparedness and have a vital oversight role to play. Trust and understanding between the health department and communities is essential.
- As raised in a statement issued on Monday by a coalition of over 150 civil society organisations, there are urgent social issues to be addressed before, during and after the lockdown, including ensuring that those most food, water and money insecure, as well as the homeless, have provision made for them during the lockdown period.
Unfortunately, many experts advise that if all of the above is not done then we may be entering into a cycle of successive lockdowns. They say modelling shows that the Covid-19 cases will start manifesting one to two weeks after the lockdown is lifted if all the steps above are not implemented simultaneously.
That’s the challenge we have to meet. We cannot afford to fail. DM