Scary truths about coronavirus: Who’s REALLY at risk – SA doctors share details

Many people are blaming the media for coronavirus panic that is sweeping the globe. But, it’s doctors who have been indicating the scale of the problem from the get-go – which is why we saw medical personnel in China wearing protective suits of the type used in Ebola outbreaks. And it is governments that have been imposing travel bans, shutting down schools and in some cases whole countries on an unprecedented scale in order to put a lid on a disease that appears to be out-of-control. The South African Association of Anaesthesiologists has distributed a Covid-19 update to its members to separate fact from fiction about the virus that erupted at the end of last year. While it’s not a good idea to panic, also don’t underestimate this nasty illness. As SASA’s Professor Bruce Piccard emphasises, Covid-19 is not a bad flu. While many will experience only mild symptoms, there are a large number of people – particularly over the age of 50 – who are at risk of becoming seriously ill. His directive sets out some preventative measures for clinicians. BizNews shares his Covid-19 update, with permission. – Jackie Cameron

Issued 15 March 2020 @ 15h30

SARS-CoV-2 or COVID-19 has been declared a pandemic, which due to exponential transmission rates can result in an infection spike which overwhelms healthcare services and resources as has been evidenced in China and Italy. 40%-70% of the planet’s populations is predicted to acquire the infection. The infection is mild in more than 85% of cases.

As frontline clinicians in this pandemic, it is essential that you understand how to protect yourselves and your families to ensure that we have a healthy workforce to manage this pandemic in the coming weeks. It is important to understand that healthcare workers were at increased risk of mortality in the early pandemic, before adequate and appropriate use of personal protective equipment (PPE) was employed. This advisory is therefore extremely important for the health of our workforce and, therefore, our patients. SASA calls upon its members to ensure a calm, rational and deliberate management of their personal well-being and that of patients in your institution/s.

Intention of this communication

1. Highlight this is a human resource and therefore healthcare system threat.
2. Deliver a practical message to enable proactive measures for when the incidence increases locally.

The human resource threat

At present South Africa is in the primary “containment” phase of a pandemic. Known Covid-19 infections are currently all “imported” with efforts directed at quarantine. This will evolve soon into community transmission where efforts are then directed at protection. The graph above highlights why protective efforts are so vital. Without protective measures (as has been demonstrated in Italy, Iran and other countries), our Healthcare system will be overwhelmed. This translates into the requirement of each of us to champion preparedness in every facility (public and private) that we work.

This is not “bad flu”

We don’t propose panic. That stated it is important to base our plans and assessments on worldwide experience.

This highlights our at-risk population (of which our profession is also a part). The first of two important highlights relate to the increased virulence and contagious property of Covid-19 (SARS CoV-2). The virus has a preferential binding of ACE receptors in the lung with the resultant clinical picture of fever, myalgia and lower respiratory tract presentation rather than a slow and progressive onset we may understand from flu. The second is the clear at-risk population – those over 50 years old, and specifically 60 years plus, and those with co-morbidity.

Because of these we need to appreciate that up to 10% of those infected will need critical care services when admitted despite 85% of infections being mild. 

Practical message

As a society we are concentrating on our collective professional responsibility to the system and our patients. These are the important actions we recommend you need to initiate immediately – divided into Personal and Workspace interventions.

A. Personal interventions

1. Know how to protect yourself in clinical practice

We recommend the following website of the WFSA: https://www.wfsahq.org/latest-news/latestnews/943-coronavirus-staying-safe .

It includes guidelines for i) Routine Care for Patients with Suspected or Confirmed COVID-19, and ii) High Risk Procedures – Intubation and other Aerosol-generating medical procedures (AGMP).

Be sure you know and practice the steps of donning and doffing PPE. The step charts of the University of Toronto are excellent: https://www.anesthesia.utoronto.ca/news/coronavirus-and-safety-precautions or reference a short video (https://vimeo.com/397604374) as an example. We recommend double-gloving as shown in the video. 

There are also training guidelines released by the National Institute for Communicable Diseases (http://www.nicd.ac.za/covid-19-training-for-clinicians/). We strongly recommend you watch this video.

2. Self-isolation practices – Do not put yourself or family at increased risk of community infection

In order to prevent the spike in infective cases which will overwhelm the healthcare system, it is necessary to focus vigorously on containment of SARS-CoV-2 in order to try and flatten the curve of infected cases. Containment involves hand washing, social distancing, avoiding unnecessary in person meetings and congregations and avoiding unnecessary travel. This is well documented in the NICD video http://www.nicd.ac.za/covid-19-training-for-clinicians/. Isolation is a critical element in stopping the spread of this infection.

3. Consider if you are at increased risk of morbidity and mortality from COVID-19, and ensure that you do not put yourself in a position for SARS-CoV-2 exposure 

High-risk factors for morbidity include; i) age>60 years, ii) hypertension and on ACE inhibitors, iii) diabetes, iv) cardiovascular disease, v) chronic respiratory disease, or vi) cancer.

A summary of general personal considerations from www.flattenthecurve.com:

B. Workspace Interventions

4. Engage immediately at a facility level in ensuring adequate preparation for COVID-19 cases and the expected surge in infected cases requiring acute care

This includes;

1. i) Planning for personal protection and PPE management, 

Frequent donning and doffing simulations are needed now. In the private sector, we would encourage each member to take that lead in their own hospitals and day hospitals.

1. ii) Plans for patient isolation of positive cases,

iii) ICU guidelines for patient isolation in ICU, and ensuring that if you treat positive patients, that you are ‘self-quarantined’ away from elective COVID-19 negative ICU patients. Please assist with designated treatment area preparedness and isolation practices and policies,

1. iv) We recommend that all surgical patients should receive a short preop screening questionnaire about risk for SARS-CoV-2 infection;

Preop screening questionnaire 

1. i) Person with acute respiratory illness with sudden onset of one of the following; cough, sore throat, shortness of breath or fever and in the last 14 days prior to the onset of symptoms met one of the following criteria; i) were in close contact with confirmed or suspected SARS-CoV-2 patient, or ii) travelled to an area with community transmission of SARS-CoV-2 infection, or iii) worked in, or attended a health facility treating SARS-CoV-2 patients, or iv) admitted with severe pneumonia of unknown aetiology. 

Any suspected SARS-CoV-2 positive patient should not have elective surgery, and should be advised to immediately to self-quarantine, and follow the suspected positive contact protocol.

v) Ensuring that your facilities have clearly communicated arrangements for the testing of staff and patients,

vi) Encourage Hospital heads to engage at a Provincial Department of Health level.

5. Know what to do if you have occupational exposure

i) If you have occupational exposure with full PPE, you can continue to work with monitoring for symptoms for 14 days. 

ii) If you have occupational exposure without full PPE, then you need to self-quarantine immediately. Do not visit your GP, but phone your GP regarding testing, and monitoring of symptoms.  As a healthcare worker needed during this critical time, SASA believes it would be appropriate for you to ensure that your testing is expedited.

iii) The testing space is particularly dynamic. As of today, in keeping with containment principles, labs will only test patients with a confirmed travel history and with fever/ myalgia/ severe viral symptoms. All other patients are referred home for self-isolation for 14 days or testing if symptoms change. This will likely evolve and change with new tests being developed (reported today that may enable a 10 minute identification test). An established NICD hotline for Covid-19 is 0800 029 999 or a WhatsApp connection at 0600 123 456.

Please note the following: 

The course of this pandemic and its impact on our healthcare system and its resources are very difficult to predict on a day to day basis, but we expect them to be dramatic. The pandemic and recommendations on best practice are changing frequently, sometimes daily. As a result, these guidelines and societal directives will be amended, as is required and appropriate, with the progression of the disease within our unique population.

SASA is working with manufacturers and will distribute guidelines for equipment sterilisation and maintenance, including anaesthetic machines used for longer ventilation.

Please follow and read all the correspondence tagged SASA COVID-19 UPDATE so as to ensure that you stay up to date with the latest recommendations in promoting the best and safest practice for you, your patients and your own families. 

SASA has established a working task team. This team is engaging at provincial, national and international levels, in both the public and private sector, including Departments of Health, the NICD, Facility Groups, Funders and other critical stakeholders. Considerations include workforce planning, public-private cohesion and interventions, remunerative structures in the case of massive healthcare resource burden and more. We will continue to provide our members with the most current and applicable guidance through the course of this pandemic. We also need to apply our unique skills to the establishment of contingency plans. 

Please remember: Your personal health impacts on the health of your patients, and ultimately the health of the nation. We need you to take care of yourselves, so that together we can work towards enabling the best possible infrastructures and systems in order to manage our patients.

Click here to view the presentation by Prof Bruce Biccard at the SASA AGM on this issue.