In episode 24 of Inside Covid-19, South African President Cyril Ramaphosa lays down the post-lockdown rules; a 500 person clinical test on BCG vaccines kicks off next week; 75,000 people contribute R2.6bn into the Solidarity Fund; low but rapidly growing UIF disbursements; and a chilling end to the episode as an ICU doctor shares how she and colleagues are preparing for the possibility that 20% of them will die from the coronavirus when the infection wave hits SA. – Alec Hogg
First in the Covid-19 headlines today:
- South Africa’s President Cyril Ramaphosa says the country will take a cautious approach to its emergence from lockdown, announcing restrictions will be reduced from the level five to four on May 1st.
- Despite the lockdown, the long feared exponential acceleration of South African coronavirus deaths appears to have begun with the Department of Health announcing that by Thursday night 75 people had died from the virus, 10 of them new representing an increase of 15%. Confirmed cases posted by far the biggest single day’s increase at 318, or almost 9%, to 3,853. The previous highest daily increase was the 251 confirmed infections on April 18. The country’s first four cases were reported on March 9. Worldometer.info confirmed global infections are just below 2.7m with deaths at over 188,000.
- On Monday, Stellenbosch University Professor Andreas Diacon will be launching a 500 person trial aiming to determine whether the BCG vaccines are indeed a shield against Covid-19. The trial involves the re-vaccination of BCG, which has been universally applied in South Africa since 1973. Numerous reports have pointed out a correlation between infection rates of countries where BCG is universally administered being far lower than in those countries like the USA, Italy and Belgium, where it was never used.
- The Solidarity Fund, launched last month in President Ramaphosa’s State of Disaster address, today announced that it has received pledges worth R2.6bn from 75,000 South Africans and around 1,000 businesses. In addition, 75 individuals have been seconded by 25 organisations to offer their services free of charge. The Fund says it has already invested R1bn in critical interventions, mainly procuring Personal Protective Equipment for healthcare workers and disbursing food parcels for vulnerable people.
- America’s unemployed swelled by another 4.4m last week, taking the job losses since the coronavirus hit to more than 26 million. And globally, economic activity collapsed with the IHS Markit Purchasing Managers Index for the US dropping from 41 in March to 27 in April, its lowest since October 2009. Its European equivalent plunged to a record low of 13 for an index where 50 is neutral. The oil price continued to recover after the extraordinary events of the past few days, with Brent Crude rising 8% to $22 a barrel, and the American benchmark WTI price up 29% to $16.50. The collateral damage from Covid-19 has been focused primarily on the economic cost of lockdowns. But today the World Health Organisation warned that the global reallocation of resources to focus on the coronavirus could double malaria deaths to more than 750,000 this year.
I love talking to the scientists, to the people on the frontline. It’s not quite a frontline yet, because we haven’t had the tidal wave hit us of Covid- 19 infections. Dr. Despina Demopoulos is an intensivist. She works in an Intensive Care Unit (ICU). Why haven’t we had this wave that so many people have been predicting?
We haven’t had the wave yet. The lockdown has tried to delay it. The lockdown has allowed us to prepare the hospital for the wave that is coming. We haven’t had it because we were delayed from where the rest of the world was. The travel ban has helped with the delay, but we’re getting there. We just started later than the rest of the world.
So it’s not like it’s going to pass us by.
Everybody hopes that would be the case, but we don’t feel that’s going to be the case. The best case scenario in South Africa would be that if it comes, we’ll be able to handle it. In other words, a lot of people are staying at home, so it gets staggered out and we manage to have enough respirators, ventilators, ICU beds, and our system can handle that over a few months, instead of just having one wave of tsunami in a month’s time with not enough resources.
Just putting ourselves, the non-scientist, the non health professionals in your shoes, you would presumably be looking at what has been happening in the rest of the world given this delay that we’ve had. Are you worried as a health care worker because we see many health workers elsewhere in the world have died from this disease.
Very worried. I sit with a couple of intensivists around the country who have contacts overseas – and have firsthand discussions and messages sent to us from our colleagues that are working in ICUs, it is quite scary. In our discussions among senior colleagues, we know 20% of us would probably die. That’s been the numbers in Italy and the first world places. Our ultimate goal in South Africa is to not lose 20% of our health care workers. We are hearing from our colleagues that 20% of us are probably going to die.
That’s chilling. One in five people. How come? Is there no way you can protect yourself?
We do hope that it won’t be that bad. I do believe. A lot of my colleagues believe If we are better in the way we manage our PPEs, if we make sure that we are on board with our PPE – in terms of donning and doffing, when we take off our PPEs that we don’t infect. If we isolate ourselves and give ourselves enough time away so that in case we get sick, you know we can be tested.
Learning from our colleagues from overseas, we’ll be able to lower that statistic to 5% or 10% and not have it at 20%. In South Africa, we are trying to be a bit more proactive. We’re lucky because we got it after our colleagues overseas who might have been caught unawares, especially in Italy. Hopefully, we’ll be able to be more protected and have had time to prepare. They haven’t had the same amount of time that we have had to prepare.
Doctor, that has got all kinds of implications. Many of the health workers in South Africa have families and have children. I guess, you’ve got to prepare for the worst even though you hope it doesn’t happen.
I’ve spoken to a couple of colleagues and have put their Wills in order. Have got their wills, and their policies sorted out. They have had hefty discussions with their families. It is quite a scary time. There have been discussions in the hospitals that we work about the frontline staff, intensivists, and doctors – if we get ill or not unable to work, what is the backup?
We’ve called on other specialists. We’ve got backup specialists, but obviously they’re not used to working in the ICU environments. We have identified a couple of specialists that are prepared to help if the frontline goes down.
They are the awesome documents going around saying that healthcare workers will be guaranteed beds in an ICU. If it becomes an absolute disaster, we’re going to have all those beds and follow some of the protocols being done overseas on deciding who gets the bed.
It is a scary time. I’ve got two young little boys. I’m obviously very scared in case something happens. I’m very particular, and a lot of my colleagues are, in terms of coming home from work showering outside not letting them have contact with you. It’s quite difficult. We’re trying everything we can to be healthy, so that if we do get sick we can recover quickly.
Is there a correlation between the amount of exposure to this virus and the mortality rate?
There is definitely correlation between the viral load and mortality rate. Those doctors who died and those who were exceptionally ill had much more exposure. So in other words, when you are filled in your eyes with Covid-19 patients, the chances are much higher that you will get more sick. It’s definitely related to the very lens and viral load. In places where there were one or two patients in the ICU and dedicated staff for that, they’re not tired and are careful, have done better.
What about older doctors and older health workers given that this virus seems to prefer – the mortality rates there are higher.
We’re trying to protect our older colleagues. Some hospitals have said no over 60 years will be involved in those patients. Which is a tough thing because a lot of our very experienced colleagues are over 60 years. We are trying to protect them from being in the frontline. We will not call upon those anaesthetists or those intensivists that are 60 years initially. The average age of 40 to 60 group, which is most of us at the moment are planning to handle that. We’ve actually not included them in our core rosters in many institutions. We’ve also advised older specialists to stop consulting.
If you spend more time with Covid-19 patients then the chances are higher that you are going to be infected and badly infected. Are you working on shorter shifts?
We are looking at shorter shifts at the moment and not because we’re not seeing as many patients. We’ve done shift work where minimum staff is going and the rest we’re taking a week apart to make sure that we don’t get ill. We haven’t cut on hours at the moment. We’ve dedicated certain staff members to Covid-19 wards and certain staff members to non Covid-19 wards. When we do hit the disaster, there will be limited time and probably 8 hour shifts vs. 24 hour shifts. We haven’t yet decided what we’re going to do with our nursing staff at the moment.
Just explain that 24 hour shift.
Depending on where you are and whether you are a junior doctor or a senior doctor. A lot of the junior doctors have to be on the floor for 24 hours. A lot of the senior doctors will be on call for 24 hours 7 days a week. That’s how we do our intensive care cover.
Therefore, most of the day we come in at night and transmit but we don’t sleep there. Junior doctors sleep there, then we get called if there’s a sick patient or an emergency. When we hit the middle of this pandemic, the intensivists and consultants will probably be much more there than the junior doctors. We’re going to put the most experienced staff to manage these patients and hope that we decrease the risk and spread to allow our health care workers.
You say when we hit the worst of the pandemic what are the timings looking like so?
It’s a difficult question. A lot of people are trying to predict it. The medical field feels that we probably can only start hitting our peak in September. Epidemiologists and statisticians have looked at models trying to compare what’s happened overseas; they’re thinking South Africa will peak around September.
Many hospitals are seeing one or two patients. Some hospitals have had patients in ICU, but there is no hospital that’s got a full ICU of Covid-19 patients. At the moment, that’s still okay. We’ve also been fortunate in terms of children – because my primary speciality is paediatrics. The kids haven’t hit us hard, but in the last week, kids have started now being admitted to hospital. The peak is going to be full probably in September. I hope that’s not the case.
Dr Demopoulous, I spent a little time with an organisation called Yabonga, who look after HIV-positive children in Khayelitsha. It was very heartwarming. But I guess not so heartwarming is the fact that these are HIV-positive kids who would be presumably more at risk to Covid-19. Is that the case?
What the South African paediatricians and specialists are concerned about is that we have the most TB and HIV in the world. No one can tell us throughout the world what’s going to happen to these patients because they don’t have the experience. It’s a bit of uncharted territory for us right now. Yes, immunosuppressed patients are. Patients with HIV, TB, oncology patients, transplant patients all those patients are at risk. We are fortunate that a lot of patients on antiretrovirals.
Hopefully they are immunosuppressed. If they are immunosuppressed, they should theoretically be – if they don’t have any other infection – should be the same as every other patient.
